A REVIEW ON EFFORTS OF HEALTH TOURISM IN TURKEY

Medical tourism is rapidly growing as the healthcare prices go up in the developed countries and inadequate medical techniques and absence of high-tech technology in the undeveloped or developing countries. Medical tourism refers to travelling to the distant destinations in other countries for health issues and medical curing possibilities. Medical tourism and health tourism concepts can be used interchangeability. Medical tourism includes four major categories: health beauty tourism, treatment, cosmetic surgery, and rehabilitation. Medical tourism is considered a significant importance for developing countries including Turkey. Turkey has become a preferred destination for medical tourism for the last two decades especially by people from neighboring countries in the Middle East as well as the Europe. In this study, it is aimed to investigate the medical tourism and its impacts on Turkey’s market. In this context, a broad literature review has been made and statistical information about the sector have been investigated.

Medical tourism is related to the activities of travelling abroad for medical purposes (Connell, 2006). Medical and health tourism could be used interchangeability. Medical tourism includes four major categories: health beauty tourism, treatment, cosmetic surgery, and rehabilitation (Gonzales, Brenzel & Sancho, 2001). There are some major concepts under these categories including illness treatment, fertility, wellness, alternative treatments, cosmetic surgeries, SPA, water treatments, acupuncture, herbal healings, surgery, recovery, agency, ecotourism, diagnostic tourism, oncological treatments, and elderly care programs.
Medical tourism is one of the fastest growing industries in the world today. The sector has been included in the scope of service export. Turkey has become the center of attraction of both foreign patients and international investors in the medical tourism industry in recent years thanks to the different geographical and cultural characteristics and service quality. Health tourism in Turkey has been promoted within the scope of foreign exchange earning services (Uyan, 2019). Turkey is a developing country that has some hospitals with advanced technologies and well-educated medical personnel. It attracts people from Middle Eastern countries and some from European countries.
This study was intended to examine medical tourism and reveal any advantageous and disadvantageous of medical tourism attempts and investments in Turkey. The study prepared in this context consists of five parts. The first part is the introduction specifying the concepts, purpose, importance and design of the study. The second part focuses on descriptions, scope and forms of medical tourism. Third part puts forward the developments of medical tourism in the world. In the fourth part, Turkish medical tourism was reviewed. Finally, the conclusions are presented and recommendations are proposed based on the information obtained within the scope of this research.

DEFINITION, SCOPE AND TYPES OF MEDICAL TOURISM
Health tourism was defined as "the organized travel outside one's local environment for the maintenance, enhancement or restoration of an individual's wellbeing in mind and body" (Carrera & Bridges, 2006). Medical tourism is a subset of health tourism. In this study, health tourism and medical tourism are used synonymously.
The medical tourism sector has been increasing around the world especially in underdeveloped or developing countries including Turkey, India, and Thailand (Bookman, 2007). For example, an American individual could visit Costa Rica, Thailand, or India for nonemergency surgery because waiting time is much higher as well as surgery and after surgery, treatment cost much more than their original country, USA.
There are several types of medical tourism around the world. Studies (Gonzales, Brenzel & Sancho, 2001) showed some prospects for developing trade in accordance with medical tourism services and identifying some trade regulations and strategy. A taxonomy in regard to the fundamental types of medical tourism was proposed as illustrated in Table 1. Their taxonomy consisted of four major medical tourism categories; "Health beauty tourism", "Treatment", "Cosmetic surgery", and "Rehabilitation". One of the most important health beauty tourism examples is alternative medical tourism such as SPA.
People have been travelling to distant destinations to get health from thermal and mineral water. The proposed health treatment tourism includes several purposes such as surgery and fertility. The table below also presents two other medical tourism forms; cosmetic surgery and rehabilitation.

DEVELOPMENT OF MEDICAL TOURISM IN THE WORLD
The increasing costs of health agencies financially influence social security institutions. In order to solve such difficulties, social security administrations and private health insurance corporations focus on providing health services for their citizens at lower cost by formulating business contracts with any neighboring countries that have quality medical facilities at lower costs (Cook, 2008). Especially thanks to the new technology in medical care, globalization efforts around the globe, and price decreases of the airline tickets in the 1990s greatly affected such medical journeys. Also, medical development in India, Turkey, Mexico, Singapore, and Thailand changed the trends towards themselves and other developing countries. Western nations started getting the same medical procedures and health operations at lower prices than in their home country.
Total revenue of medical tourism and related treatments has been growing at a fast rate in the last three decades according to the international reports and studies. Also, the number of medical tourists has been growing and increasing incomes from it are regularly reflected on the media sources. Medical tourism in India created a total of $1 billion in 2012 and growing since then. Also, the medical tourism industry reached a total of USD 20 billion worldwide in 2006 and doubles in 2010. But, such figures were not reflecting the total picture of this system since some of them are not included in the calculation (NaRanong & NaRanong, 2011).
Thailand, a popular medical tourism destination, has been greatly increasing since the 1990s, but few scientific types of research have been conducted on this topic. The medical health care market for the medical tourists was estimated between $1.5 billion and $2.5 billion for the year of 2012 (NaRanong & NaRanong, 2011). That was only 0.4% of their GDP. Another study showed that many American citizens travel abroad to get medical treatments. An estimated value of $1 billion spent on such travels and considered a loss to the US medical care system and the US economy (Connell, 2006). As can be seen in Treatment tourism has the biggest revenue and number of tourists in Turkey. In terms of treatment tourism, cardiothoracic and cancer treatments are two most popular purposes for the medical travellers. Diagnostic tourism, eye surgery and fertility treatments are other popular types of treatment tourism. It is very important for Turkey to offer such medical tourism forms because such services are extremely expensive in countries such as the USA.
In Turkey, thermal tourism is one of the main areas offered for the elderly and disabled tourists (Republic of Turkey Ministry of Culture and Tourism, 2018). One of the most important destinations is Pamukkale in the vicinity of Denizli. In addition to the historical sites and destinations in the region, thermal water baths, pools, and other related facilities are very important for medical tourism to offer their guests desired goals. Several destinations exist in Turkey regarding SPA and related medical tourism such as Istanbul, Izmir and regions, especially near Aegean and Mediterranean coasts. Such medical tourism services are generally preferred by the retired people especially from the European countries, the USA, and Canada (Republic of Turkey Ministry of Health, 2018).

Current Medical Tourism Situations in Turkey
The number of medical tourists who preferred Turkey for their medical issues for the last decade  . The highest medical health care spenders reside in developed countries and were above the OECD average. The first top three countries who spent the highest medical health care were the United States, Netherlands, and France. Turkey ranked 37th among the 40 countries included with only higher than Russia, China, India and Indonesia. This rank put Turkey among the most preferred destinations for medical tourism.
1. In the Netherlands, it is not possible to clearly distinguish the public and private share related to investments.
3. Health expenditure is for the insured population rather than the resident population. In addition, medical tourism expenditures in the world are approximately 500 billion dollars. Of the 178.000 people who visited Turkey for medical purposes, 67% visited at private hospitals while 33% preferred public or university hospitals (İçöz, 2009).

Factors Affecting Medical Tourism in Turkey
Turkey lies between Europe and Asia. It is on the border of the European Union countries. In addition, Turkey hosts an international operating airline company, Turkish Airlines. Such prospects make it easier and more affordable to travel for medical tourists. According to İçöz (2009), as a result of conversion policies in the health care system, the quality of services has increased at public and private hospitals in Turkey. Turkish government passed related laws and regulations for medical tourism in 2017. Quality service and suitable price advantageous in the world, Turkey ranks among the top ten medical tourism destinations (Özsarı & Karatana, 2013).
Although Turkey offers a high quality of medical services, some shortages affect the perception of the quality in the sector (Republic of Turkey Ministry of Health, 2018). Several direct or indirect issues arise for the development of the medical tourism efforts in Turkey as health services are not planned effectively and principally sufficient (İçöz, 2009). An important issue that negatively affects the medical travel is the lack of employees with the knowledge of a foreign language (Republic of Turkey Ministry of Health, 2018). Another issue is the brain drain of physicians to developed countries (Kılınç, 2017). One of the main concerns is that the world's leading destinations in which Turkey is competing in health tourism are expected to allocate more budgets for health tourism than Turkey. Another concern is that the likelihood of the reflection of the neighboring countries' economic, social or political confusion to the region where Turkey is located (İçöz, 2009).
In order to overcome such shortcomings, sector stakeholders (e.g. business, government, and travel agencies) should be emphasized as well as strategies for eliminating weaknesses. They should function properly to maintain competitiveness in medical tourism. Medical tourism in Turkey is estimated to grow faster if the medical tourists are willing to pay more attention, healthcare services become competitive, and cost differences remain the main factor (İçöz, 2009). In the case of fulfilment of the required conditions, Turkey can become a leader in the international health tourism market.

CONCLUSION
Medical or health tourism has been growing at a fast rate for the last few decades both in Turkey and around the world. The factors such as rising medical costs, long waiting times, and not having medical insurances caused the individuals with medical conditions to travel destinations including Turkey. Medical tourism has been considered one of the most important businesses, especially for developing countries. In terms of these countries, it is possible to obtain a crucial income through this business.
The number of people who visit Turkey for medical reasons has been growing for the last decade. Medical tourism in Turkey has been attracting more medical tourists since it is a developing country and offer health care and medical treatments at lower affordable costs. Also, Turkey has accredited medical institutions, important hotel chains, and famous destinations. Therefore, Turkey is active in all sections of medical tourism including thermal, treatment, cosmetic surgery, and rehabilitation.
Turkish medical tourism has several difficulties such as language barrier of the personnel, shortage of physicians, confusion in the region where Turkey is located, and insufficient budget allocation to promote the sector. In order to achieve to cope with these problems, politicians, decision makers, and tourism entrepreneurs should work together collaboratively. Governments and investors should increase the quality of their services in order to attract more customers abroad. In addition, public pays can be kept low to compete with rivals in the industry. However, stakeholders should be careful about the steps they take because the progress should also make the citizens and public satisfied. To minimize negative perceptions regarding the Turkish medical facilities, they should be examined, and practices should be implemented. Also, the number of highly qualified medical personnel should be increased.