Medical tourism, a phenomenon closely tied to the forces of globalisation ^[1], has emerged as a result of heightened accessibility to cost-effective air travel alternatives and enhanced cross-border digital communication channels. At the global scale, medical tourism is a sector that is supported by a population of 617 million citizens, experiencing a yearly expansion of 3.9%, and carrying an estimated value of USD 513 billion. The medical tourism business is seeing rapid growth on an international basis, resulting in a substantial revenue of USD 20 billion for various places worldwide ^[2]. The globalisation of health services is a direct outcome of the use of cutting-edge technology in strategic medical tourism marketing ^[3]. These advancements have enabled medical practitioners in one nation to effectively promote their services to potential patients located in foreign territories ^[4]. Concurrently, the escalated movement of healthcare professionals across international borders for educational pursuits has led to a scenario in which medical practitioners rendering services in middle- and low-income economies possess comparable qualifications to their counterparts in high-income Western European and American nations. This trend has been paralleled by an upsurge in foreign direct investments targeting the healthcare providers situated in host countries ^[5]. The escalating endorsement of healthcare portability is notably conspicuous in Europe, where heightened patient mobility prompted the formulation of a European Union directive addressing cross-border healthcare ^[6]. This confluence of factors, alongside a rise in out-of-pocket expenditures on healthcare within numerous high-income nations during a period of economic turmoil, synergistically form an ideal market for medical tourism.

Yet, an understanding of medical tourism remains limited. Little information is available about which patients choose to travel and why, and why others do not. Data on the patient flows and resources spent remain uncertain ^[7]. “This has hampered efforts to understand the economic costs and benefits to countries experiencing inflows and outflows of patients. Similarly, for the medical tourism industry, the role of private providers brokers and marketing remain a black box” ^[8]. Although there has been an increased focus on this matter in the last ten years, the complete impacts on patients and health systems remain not entirely understood. This study, apart from presenting the perspectives of the “protagonists” of medical tourism in Crete (tourists, medical professionals, and hotel managers), also highlights the capacity of the health system in the study area to address the needs of medical tourism. This issue has not been studied before, although Crete is a key region for medical tourism in Greece.

Crete could justifiably be considered the region of Greece that has made the most strides toward the creation and development of medical tourism services. On the world-famous tourist island, which has ideal climatic conditions and a rich cultural heritage, making it a suitable place to combine vacations and use health services simultaneously, the first Greek medical tourism centres have already been established, operating in various fields such as ophthalmology and endocrinology, serving patients with kidney failure and more.

A series of factors that coexist on the island of Crete offer great prospects for the successful combination of health services and tourism. First of all, Crete—like several other Greek regions—has ideal climatic conditions and a rich cultural heritage, making it a suitable place to combine vacations and the simultaneous use of health services ^[9]. Furthermore, the island has many high-quality clinics, a university hospital, nine hospitals in total, and a plethora of distinguished doctors of various specialties, as well as high-standard hotels ^[10]. Moreover, high-class hotels are willing to invest in medical tourism, since they have the capacity and know-how to develop it ^[11].

It should be noted that tourism is one of the main sources of income for Crete, as it comprises almost 48% of its regional GDP, while it amounts for 23% of the overall tourism revenues in Greece ^[9]. Given the crisis in traditional forms of tourism, and the favourable factors mentioned above that exist on the island, the prospects for further development of medical tourism services are extremely high.

The term “medical tourism” was initially coined in 1973 by the International Union of Tourist Organizations (IUTO), the precursor to the World Tourism Organization (UNWTO). It pertains to “the provision of health services that use a country’s natural resources, especially mineral, water and climate” ^[12]. In a perfectly succinct way, the World Tourism Organization describes medical tourism as the activity of travellers who elect to travel overseas in order to undergo various types of medical treatment, encompassing a comprehensive spectrum of medical services ^[13]. In recent decades, there has been a global increase in the movement of patients, healthcare professionals, medical technology, financial investments, and varying regulatory systems among countries. This phenomenon has led to novel healthcare consumption and production patterns. This emerging trend is primarily attributed to the growing trade in healthcare, involving the cross-border mobility of patients seeking medical treatment, commonly known as “medical tourism” ^[4]. Medical tourism encompasses instances where individuals choose to travel internationally in pursuit of medical treatment, spanning a broad spectrum of medical services, which most commonly include dental care, cosmetic surgery, and fertility treatments. Notably, patients from more affluent and developed nations frequently travel to less developed countries for healthcare services, motivated by the low-cost treatments available in the latter, coupled with economical flight options and the availability of online information sources [14,15]^[14][15]. It is important to clarify that health tourism and medical tourism are two different concepts, despite the fact that both address the health sector. For the existence of medical tourism, the existence of health tourism is a necessary condition ^[14]. More specifically, in accordance with the Greek Law 4582/2018, health tourism encompasses medical tourism, thermal tourism, and wellness tourism. More analytically, medical tourism pertains to the movement of visitors or tourists who are grappling with health concerns or chronic diseases to a selected tourist destination. The primary purpose is to access health services provided by lawfully operating primary or secondary healthcare facilities. This is aimed at disease prevention, diagnosis, treatment, and the enhancement or preservation of personal well-being. Tourists/visitors, during their stay, combine medical treatment, information, transportation, and entertainment with activities at the tourist destination for themselves and their companions. In other words, health tourism and medical tourism are alternative forms of tourism ^[16]. Furthermore, the advancement of medical tourism presents a distinctive prospect for prospective investors, capitalising on the global upsurge in medical tourism and the escalating profitability within this sector. Particularly noteworthy projections suggest that the medical tourism market’s magnitude is poised to expand significantly, ranging from USD 115 billion to USD 346 billion between 2022 and 2032 ^[17]. An evaluation conducted in 2013 by the World Medical Tourism & the Global Healthcare Congress projected that the aggregate medical tourism market could potentially contribute up to 16% of the comprehensive revenue generated by the broader tourism industry by the present year. This market exhibits the potential to provide a substantial economic impetus to the Greek economy, contingent on the allocation of adequate attention and effective cultivation ^[18]. Investing in wellness tourism offers immense benefits to investors in the global wellness tourism industry. Wellness tourism, by definition, encompasses tourist activities strategically oriented toward augmenting and enriching an individual’s holistic well-being, encompassing physical, psychological, and spiritual dimensions. This mode of tourism entails participatory engagements in a spectrum of activities ranging from yoga, spa treatments, meditation, and Pilates, to visits to thermal spring retreats. Additionally, the emerging inclination towards interactions with local inhabitants of the travel destination, who have encountered diverse cultures and experiences, contributes to the enhancement of personal well-being ^[19]. Particularly notable, the wellness tourism sector has exhibited remarkable growth, recording a valuation of USD 814.6 billion in 2022. Projections indicate a trajectory of sustained expansion, envisaging a compound annual growth rate (CAGR) of 11.8% from 2023 to 2030 ^[19]. Medical tourism is a significant issue for the European Union (EU). If the indirect productivity benefit of medical tourism is omitted, the empirical data imply that medical tourism overestimates a host country’s economic contribution by about 27% ^[20]. As Greece is a member of the EU, it is crucial to consider the challenges the EU encounters in relation to medical tourism and in what ways the EU can potentially contribute to the emerging market in Greece. One of the challenges that Europe is currently facing regarding health tourism is how to balance two goals: the first one is to ensure that goods and services, that are provided across borders, are of adequate quality, and the second one is to ensure that the freedom of movement is not limited by one’s health, meaning that healthcare is accessible when one travels abroad. Therefore, the question that needs to be addressed is whether European citizens can be confident that they will receive high-quality healthcare services whenever they are needed outside their home country [21,22]^[21][22]. The initial measure to be taken is to guarantee that every country has efficient policies for ensuring the quality of healthcare services. These policies should encourage healthcare that is suitable, effective, tailored to the patient’s requirements, and patiently oriented ^[23]. The adoption of cutting-edge medical technology has the potential to elevate patients’ impressions of medical tourism and increase the industry’s overall growth rate. Understanding and acknowledging these features is crucial to the success and acceptance of medical tourism. Suitable policies should be established at every level, including the overall healthcare system [24,25,26]^[24][25][26]. This involves implementing mechanisms that can guarantee the quality of the key components of the healthcare system, such as pharmaceuticals (through the process of registration and licensing), technology (through an HTA or Health Technology Assessment), and healthcare professionals (through training and lifelong education) ^[27]. Some national policies may be influenced by European frameworks, for example, in the case of the approval of pharmaceuticals, which has been largely determined by the activities of the European Medicines Agency (EMA). At a clinical level, policies should be in place to improve the procedures and the results of healthcare such as developing and implementing monitoring systems like quality indicators and patient surveys, and quality assurance systems to ensure that the quality of care is maintained and improved over time [28,29]^[28][29]. These systems typically include clinical governance arrangements and audit processes. Furthermore, organisations, facilities, and practitioners have various options, frequently optional, to evaluate the quality of healthcare they offer. These options may entail evaluation by peers or comparison with other providers. Such mechanisms include peer review, accreditation, and involvement in European initiatives such as the ISO-9000 ^[30] and EFQM [31,32,33,34]^{[31][32][33][34]}. Despite acknowledging the numerous constraints in the data available, it is evident that there is significant diversity among and within EU member states in terms of their strategies and implementation of programs to guarantee the quality of healthcare ^[35]. However, there are certain elements that are universally or nearly universally applicable, mainly those linked to the safety of pharmaceuticals. Nevertheless, in different fields, for example, when it comes to the quality of clinical activities, there is significant heterogeneity, such as the level of obligation for these activities or their voluntariness. Moreover, there is variability in the degree to which information systems have been developed to facilitate quality assurance initiatives. This encompasses the technicalities of patient databases and their utility in the context of disparities in data protection legislation interpretations ^[35]. According to data from the EU medical tourism database, it is estimated that in 2014, medical tourism in the EU included about 56 million trips within the country and a little over 5 million trips from international visitors. This adds up to a total of 61 million trips related to medical tourism in EU countries for that year. Medical tourism makes up around 4.3% of all entries into EU countries. This means that medical tourism trips only make up about 5.8% of all trips within a country and about 1.1% of trips from other countries ^[21]. Wellness tourism takes the lead in the realm of health tourism in the EU, accounting for approximately two-thirds to three-quarters of the entire market. In 2014, the earnings generated from medical tourism in the EU summed up to EUR 47 billion, comprising 4.6% of the entire tourism revenue and 0.33% of the EU’s Gross Domestic Product ^[21]. When compared on an average scale, the contribution of medical tourism remains relatively modest, given the substantial tourism markets possessed by leading players both within and outside the EU. While the exact count of medical travellers arriving from non-EU nations remains undisclosed, it is presumed to make up around 6% of the comprehensive tourism market [21,36]^[21][36]. A substantial portion—over three-quarters—of the revenue generated from medical tourism within the EU originates from merely five countries: France, Germany, Italy, Sweden, and Poland. Meanwhile, countries such as Finland, Bulgaria, Germany, Spain, and Ireland excel in offering top-notch wellness amenities and lodging facilities. Notably, the highest demand for accommodations featuring health and wellness provisions is observed in Central and Eastern Europe, in addition to Spain and the Southern Baltic Coast. It is important to highlight that the most substantial portions (>10%) of the medical tourism market are witnessed in Finland, Latvia, Slovakia, Hungary, and Portugal ^[21]. In summary, empirical investigations indicate that medical tourism holds significant potential for bolstering the Greek economy ^[37]. Particularly within the context of Greece grappling with economic challenges, juxtaposed against its status as a nation both confronting adversity and harboring globally renowned specialists, the prospects for reaping advantages from this undertaking are discernible. Pertinently, medical tourism stands to yield favourable outcomes by extending the tourist season, thereby achieving an equitable dispersion of tourist influx both spatially and temporally. Operating as a notably lucrative industry (with a market size estimated at USD 115.6 billion in 2022 and expected to surpass USD 346.1 billion by 2032), medical tourism further contributes to its positive influence ^[17]. Noteworthy is the demographic shift that has taken place, wherein the 65+ age cohort constitutes around 20% of Europe’s overall population ^[38]. This demographic transition unequivocally positions medical tourism as a dynamic sub-sector within the tourism domain. Consequently, this demographic cohort emerges as a prominent force in shaping contemporary travel patterns, characterised by the convergence of time availability, requisite financial means, and a palpable inclination for intra- and inter-country travel ^[39].