The international movement of goods, services, capital and people in the context of health services is an accepted and contemporary actual phenomenon. People who demand international healthcare services to cure a health problem or to be healthier are called “international patients.” International patients can be evaluated in three groups: “medical tourists”, “tourist’ healthcare” and “healthcare for refugees”. The most important difference between the terms “medical tourist” and “tourist’ healthcare” is that the former travels abroad for the purposes of healthcare and the main travel purpose of other group is leisure, businesses etc. However, the term “healthcare tourism” embodies both groups as a whole. Healthcare tourism is not restricted to only surgical intervention and may involve many different aspects from check-ups to special practices that require skilled medical interventions.

As the term suggests, receiving healthcare services in a country other than one’s own is defined as “healthcare tourism.” Because the description is based on the country of residence rather than citizenship, diaspora populations emerge as important factors in healthcare tourism. When a person travels and arrives at the target destination, such a person is called a “medical tourist” (or healthcare tourist), and all activities (medical services, hospitality, traditional cultural tourism etc.) from door to door during this trip are called “Medical Tourism”.

Up to millennial change, people from developing countries traveled to developed countries for medical procedures that are unavailable in their countries due to immature healthcare facilities and infrastructures. However, in recent years, people of developed countries have also started traveling to developing countries in order to get cost-efficient medical services without waiting time. The increasing tendency of international patient movement for various reasons encompasses the last two decades [1]. Also, medical tourism is one of the most fastest emerging industrial sector of today. Medical tourism has emerged as a consequence of the globalization of health services and it certainly exhibits strong growth potential globally [2,3].

Besides being technologically advanced medical infrastructure, Turkey is a leading healthcare tourism destination with many advantages such as cultural features, attractive traditional tourism facilities, and unique cross-continental geographical location. Also, Turkey hosts many refugees because of the regional instability. By definition, health services for refugees can be accepted as healthcare tourism. According to the 2015 UNWTO (UN World Tourism Organization) numbers, Turkey is ranked 4^th in traditional tourism among European countries after France, Spain, and Italy [4]. According to the studies done by different authors and various reports, it is demonstrated that Turkey has a similar ranking in healthcare tourism as well [5].

It is necessary to present the current status of the countries with respect to healthcare tourism in an academic context based on data, and to develop strategies and policies accordingly. It is also crucial to analyze and report the data in specific periods for the purposes of assessment and evaluation to develop and apply strategies and policies.

The aim of the present study is to evaluate the current status of Turkey with respect to international patients in accordance with the data collected in 2015 and 2016 with comparison each other [6].

Study materials and data were obtained from the open source publication titled “International Patient Report, Turkey 2015–2016” [7] published by the Ministry of Health (MoH). The respective report was shared publicly by the MoH in Turkish, and submitted for academic evaluations.

In the report, Turkey’s current status in healthcare tourism was analyzed and evaluated quantitatively on the basis of different variables of medical tourism such as the country of origin of the patients, destination cities, monthly distributions, seasonal changes, preferred hospital types, admitted clinics. The data used in the study were from 2015 and 2016. The current status of Turkey in terms of healthcare tourism was presented to the researchers along with the numbers submitted for discussion [8-11].

Frequency and percentages were used in the data analysis within two group as “medical tourist group” and “tourist healthcare group”. The data and the context of the report only included international patients within the context of medical tourism and tourist healthcare. Because of insufficient data, figures for thermal healthcare tourism, tourism for the elderly and disabled, and healthcare services for refugees, which are also evaluated within the context of healthcare tourism were not included in this report.

Number of international patients and arrival patterns

The numbers of patients who received healthcare services in Turkey in the context of medical tourist and tourist healthcare between 2008 and 2016 are given in Figure 1. As shown in graphic, there was a steady increase in the number of international patients coming to Turkey till 2015 and peak level was in 2014. The number of international patients who received healthcare services in Turkey decreased by 20% in 2015. The decrease in private healthcare institutions was approximately 26%, whereas the decrease in public healthcare institutions was approximately 8%. Although the tendency of downtrend subsided in 2016, it still resumed.

Figure 1: Number of International Patients by Years, 2008-2016.

Even though there was a 16% increase in the number of international patients who received health services in public institutions in 2016. In the same year, there was 21% decrease in international patients number in private healthcare institutions, which are the main actors in medical tourism. As a result, in 2016, the overall patients number decreased by 8% in total. The main reasons for the downward trend in the number of international patients receiving healthcare services in Turkey in 2015 and 2016 may be stated as the following: lack of data entry by private healthcare facilities, decrease in tourism in general and regional political instability.

There was a total of 392,950 international patients who received healthcare services in Turkey in 2015 according to the data entered via the related software. 56% services received were in tourist healthcare group, and 44% services received were in medical tourist group. In 2016, there was a relatively small decrease in both groups, compared to 2015. Because the decrease in the medical tourists group patients is relatively high, the decrease in overall healthcare tourism cannot be explained solely with the decrease in the number of tourists coming to Turkey.

Distribution of international patients by country of origin

Among the top 10 countries from where international patients come from to receive healthcare services in 2015, Libya was ranked first with 45,118 patients, whereas Germany was ranked first in 2016 with 21,759 patients. The characteristics of the countries that were ranked the top 10 are, that they are countries within 4 h flight distance, neighboring countries, countries with predominantly Muslim populations, countries with a major Turkish diaspora population and countries that provide a large number of tourist entry in general.

Number of citizens among the top 10 countries from where most of the international patients came to receive healthcare services in 2015 and 2016 with respect to types of healthcare tourism are given in Table 1. As shown in the table, 52% international patients coming from the top 10 countries received services in tourist healthcare group in 2015, whereas 48% received healthcare services in the context of medical tourist group. In 2015, most of the medical tourist group patients came from Libya and most of the tourist healthcare group patients came from Germany. In 2016, 60% people from the top 10 countries received healthcare services as tourist healthcare, whereas 40% received healthcare services as medical tourist. In 2016, highest number of patients came from Libya in medical tourist group even with a 65.7% decrease compared to 2015, while the largest patient group in tourist healthcare group was composed by German citizens (Table 1).

Table 1: Patient Arrival Patterns from Top 10 Countries, 2015–2016.

Distribution of international patients by cities

In 2015, Istanbul occupied the first place among cities where patients received healthcare services as medical tourist and tourist healthcare in Turkey. Other mostly preferred cities were Antalya, Ankara, Izmir and Mugla, respectively. In 2016, Istanbul was also ranked first, followed by Ankara, Antalya, Izmir and Mugla, respectively (Table 2). When top 5 destination cities for both years are examined; they have common characteristics such as being attractive cities for traditional tourism in general, being brand cities, having better healthcare tourism infrastructure and having easy transport options. These cities are also advanced cities of Turkey in terms of both public and private healthcare facilities. The differences between 2015 and 2016 are given in Table 2. As the table suggests, there was a significant decrease in the number of patients in all cities except Ankara. Antalya and Mugla where the decrease was the most critical are cities in the Mediterranean coast, which host most of the traditional touristic visitors coming to Turkey. The decrease in the number of traditional tourists in 2016 also affected healthcare tourism as well. The findings suggest that the quantitative decrease in Antalya and Mugla was because of the decrease in the number of services in the context of “tourist healthcare,” which is important for both cities. However, when the top 5 cities are examined, the decrease in the number of medical tourism patients (-21.4%) was higher than the decrease in tourist healthcare group (-12.1%).

Table 2: Top 5 cities providing treatment to highest number of the patients, 2015-2016.

Distribution of international patients by hospital types

In 2015, 66% international patients in Turkey received healthcare services from private hospitals, 23% from university hospitals, and 11% from public hospitals. In 2016, the most preferred healthcare facilities in Turkey were again private healthcare institutions and organizations with a percentage of 56%. The private sector was followed by university hospitals with 25%, and public hospitals with 19%.

In 2015, approximately 51% international patients who received services from private healthcare institutions were in tourist healthcare group, whereas 49% received services in medical tourist group. In the MoH affiliated institutions (public hospitals), the proportions were 88% for tourist healthcare group, and 12% for medical tourist group. The percentages in university hospitals were 54% for tourist healthcare group, and 46% for medical tourist group. Approximately 73% medical tourists preferred private hospitals, while 24% preferred university hospitals, and 3% preferred public hospitals. In 2016, approximately 62% healthcare services provided to international patients in the private sector healthcare facilities were in tourist healthcare group, and 38% were in medical tourist group. Approximately 58% patients admitted to public hospital received services as tourist healthcare, whereas 42% received services as medical tourist. In university hospitals, 46% patients received services as tourist healthcare, and 54% received services as medical tourist (Figure 2).

Figure 2: Arrival Patterns of International Patients by Hospital Types, 2015-2016.

Distribution of international patients by clinics

The clinics which provided the highest number of services to international patients who received healthcare services in Turkey in 2015 and 2016 are shown in Figure 3. According to the findings, both in 2015 and 2016 international patients received the highest rate of services in emergency medical services in A&E departments in the context of tourist healthcare. Despite the changes in the order, A&E clinics were followed by Ophthalmology (Eye diseases) and Gynecology and Obstetrics (OB/GYN) clinics both years.

Figure 3: Mostly Admitted Clinics by International Patients, 2015-2016.

When the data in Table 3 is evaluated for medical tourist group, Ophthalmology clinics were the most popular clinic in 2015, followed by OB/GYN and Pediatrics clinics.

Table 3: Admission Patterns to Most Preferred Clinics, 2015-2016.

On the other hand, none of the patients which admitted to the A&E clinics were in the medical tourist group, while about 70% of the dermatology patients were in this group. Admission to the orthopedic clinics, which is expected to take up a significant number of patients in the context of tourist health due to traumatic conditions, was found in about equal for two groups. In the medical tourist group in 2016, OB/GYN clinics were the most admitted clinics, followed by Ophthalmology, and Orthopedics & Traumatology clinics. Cardiology, Urology and Oncology clinics, which are not listed in Table 3 that provided the highest percentage of services in total (medical tourist+tourist healthcare), were among the top 10 clinics in the medical tourist group.

Distribution of international patients by months

Figure 4 shows the number of healthcare services international patients received from different healthcare institutions by months in Turkey. According to the data, August was the foremost month in number for international patients who received health service in Turkey in both years. Moreover, the number of tourists who received healthcare services in the summer months were greater when compared to other seasons. We compared six-month periods of May-October (peak season in traditional tourism in Turkey) and November-April (off-season) in 2015. Our results showed that 59.97% patients received healthcare services during the peak season, whereas 40.03% received healthcare services during the off-season in 2015. The rates for 2016 were 55.96% and 44.04% respectively.

Figure 4: Distribution of International Patients by Months They Received Healthcare Services, 2015-2016.

The admission types of patients who received healthcare services in Turkey by months in 2015 and 2016 are shown in Table 4. According to the data, 55.92% (219,775) of the admission to healthcare institutions were in the tourist healthcare category, whereas 44.08% (173,175) were in the medical tourist category. Similarly, 57.71% (207,548) of the registrations to healthcare institutions in 2016 were in the tourist healthcare category, whereas 42.29% (152,120) were in the medical tourism category. There was a direct correlation between patient numbers in tourist healthcare group and tourist number in the peak season of traditional tourism. This 6-month period known as “peak season in traditional tourism” in the table was highlighted with gray. The fact that Turkey attracts many tourists during the summer season and some of the tourists need healthcare services. This resulted in the higher number of admission to A&E clinics by tourists in Turkey during the summer months in the context of tourist healthcare.

Table 4: Arrival Patterns of International Patients Who Receive Healthcare Services in Turkey by Months.

When we evaluate Table 4, seasonal characteristics of patients within the medical tourist group was not statistically significant. In fact, the number of patients in medical tourist group who preferred the peak season for treatment in Turkey was 53.20% in 2015, whereas it was 48.84% in 2016. When both years were evaluated, 51.19% patients preferred the peak season and seasonal difference was not statistically significant. When the same numbers are evaluated in the context of tourist healthcare, 65.30% patients received healthcare services during the peak season in 2015, whereas 61.19% patients received healthcare service during the peak season in 2016. When the patients from both years were evaluated cumulatively, 63.31% patients received tourist healthcare services during the peak season. Depending on collected data in line with the example of Turkey, the patients who are evaluated within the medical tourist group do not present seasonal distribution and that they travel in any month to receive healthcare services.

As shown in Figure 5, there was no significant difference between the peak season and off-season healthcare service demands of medical tourist group patients in 2015 and 2016. However, the same Figure also indicates that healthcare services received in the context of tourist healthcare increased significantly during the peak season.

Figure 5: Seasonal Change in Patients in the Context of Medical Tourism and Tourist Healthcare.

The medical tourism sector is driven by many factors. These are such as growing geriatric population, high treatment cost in developed economies, long waiting times in developed countries, availability of cost-effective and high-quality treatments in developing countries, development of effective travel opportunities, assistance from host country governments, availability of state-of-the-art medical technologies through the world, new health insurance policies, rapid development of communication technology etc. (A). For example, the advances in the transportation industry and lower prices offered rendered international travel to be available for all rather than only for people have high incomes. Provision of high-quality healthcare services with lower prices and minimization of transportation costs which in turn affected the total budget of healthcare services in a positive manner and widened the target population for healthcare tourism [11].

There are various pull (attractive) and push (repulsive) factors affecting the mobility of patients with respect to healthcare tourism [3]. Turkey occupies a leading position with attractive pull factors such as traditional tourism opportunities, ease of transportation, lower prices, post-treatment accommodation, and cheaper living expenses. Even though there was a decrease in the recent periods because of problems of regional social stability, 2,360,178 (2008-2016) patients and 1,928,270 (2012–2016) patients preferred Turkey for treatment as noncitizen in the last 9 and 5 years respectively. Despite the decrease, the number of patients increased by 327% in 2016 compared to 2010. Although healthcare services provided for the refugees who are predominantly of Syrian origin are theoretically considered in the context of healthcare tourism, they are not included in the present study. According to the data from the MoH, Syrian refugees received more than 20 million polyclinic services, approximately 968.000 in-patient services, 824.796 surgeries between April 29, 2011 and September 30, 2016. Moreover, 177.568 Syrian refugees gave birth within the borders of Turkey. If the figures are included in the statistics of healthcare tourism, Turkey is one of the biggest healthcare destinations.

The report which prepared by MoH was the main material of the present study. But data on “hair transplantation procedures” were not recorded in this report. These procedures are accepted as the most provided international healthcare procedures in Turkey. In the evaluation of this study, exclusion of this group which provides an important international patient source for medical tourism should be taken into consideration.

In 2017 Euromonitor report, it is stated that Istanbul is the eighth city to receive highest number of tourists, whereas Antalya is the twelfth city in the world [6]. The fact that these two cities are among the most important destinations of traditional tourism in Turkey have an effect on their importance in healthcare tourism as well. Similarly, in the same report, Mugla is ranked the 62^nd city to receive highest number of the tourists, and this explains Mugla being the top 3 cities in the context of tourist healthcare.

As a general trend in health tourism, it is known that private health institutions are preferred more than public and university hospitals. Even though the role of private healthcare institutions and organizations are more important in healthcare tourism in Turkey, still ranks low compared to world average [8,9]. This was due to many reasons such as the fact that the private health sector was reluctant to share patient records with the exception of the decrease in the number of medical tourists who preferred private health institutions.

The effects of healthcare tourism mobility on public’s or individual’s health have not been researched sufficiently [10]. Countries which demand a main role in healthcare tourism conduct advertising activities, and these activities contribute to the sector as attractive pull factors. Many countries including Turkey define themselves as “medical hubs” [10]. Moreover, Dass [11] in an article published in Forbes stated that Turkey is one of the most important healthcare tourism destinations.

At an international level, the World Bank (WB) demands countries to increase their market share with respect to the development of healthcare economy. However, WB economists have disputes over personal health insurances to cover healthcare services abroad which may result in the notion of “portable health insurance” [10]. However, increasing patient traffic supports the hypothesis that there is a tendency to support patients to receive healthcare services in a different country by their personal decisions.

World Trade Organization (WTO) is looking for a solution to provide global healthcare services [10]. In fact, the founding purpose of WTO is the removal of barriers in international trade, and regulation in all sectors including service trade. Naturally, WTO supports global sharing of healthcare provision beyond borders.

The main reasons for the downward trend in the number of international patients receiving healthcare services in Turkey in 2015 and 2016 may be stated as the following: lack of data entry by private healthcare facilities, decrease in tourism in general and regional political instability. That shows traditional tourism and medical tourism affected by regional political changes. In other words, there is a direct relationship between regional political stability and both traditional tourism and medical tourism. Because the decrease in the medical tourists group patients is relatively high, the decrease in overall healthcare tourism cannot be explained solely with the decrease in the number of tourists coming to Turkey.

In line with the example of Turkey, it may be suggested that the patients who are evaluated within the medical tourist group do not present seasonal distribution, and that they travel in any month to receive healthcare services.

Providing open access to studies similar to “2015-2016 Turkey Healthcare Tourism Report” published by the ministry will allow for a comprehension of the size of the sector. It will also enable institutions such as WHO, WB, WTO, UNWTO to develop specific standards in their reports, and to regulate healthcare tourism activities.

To prevent uncontrolled economic development and to contribute to the improvement of socio-demographic index in developing countries, the evaluation of the export and import of healthcare services should be evaluated as a commercial concept.

The MoH report also states that some information may have been entered incorrectly due to user errors. There are efforts to complete and revise the data by the General Directorate of Healthcare Tourism in affiliated institutions and organizations. Consequently, the relevant report was analyzed for the purposes of the present study with the data provided.