1.1. Medical Tourism

1.2. Sustainable Medical Tourism

i.

Environmental Sustainability: This might involve initiatives to minimize the ecological impact of medical tourism, such as reducing carbon emissions, minimizing waste, and promoting eco-friendly practices.

ii.

Economic Sustainability: This could include measures to ensure the economic stability and prosperity of the medical tourism industry over time. It may involve creating financial models that support ongoing growth and development.

iii.

Social Sustainability: This aspect may focus on ensuring that the benefits of medical tourism are distributed equitably among the local communities, promoting cultural sensitivity, and safeguarding the well-being of visitors and locals.

Incorporating sustainability factors in the context of the Greek medical tourism industry could involve strategies and practices that not only enhance the quality of medical services but also contribute to the long-term health and resilience of the industry and its surrounding environment ^[7][10][12][7,10,12]. In conducting a literature review on medical tourism in Central Macedonia/Greece, with a specific focus on its connection to sustainable development issues, a deficiency in the existing literature becomes evident, with only a limited number of studies available. The present research serves to address and bridge this gap in the literature to which other relevant research has been referred ^{[8][17][18][19]}[8,17,18,19].

2. Medical Tourism in Greece

To begin, it can be stated that Greece encompasses all four essential elements for specialized tourism: “Sea, Sun, Sand, and Surgery” [13]. Nevertheless, the field of medical tourism was uncharted territory for Greece until recently. Before 2011, it was not considered a significant player in this sector, as indicated by international forecasts from the Medical Tourism Climate Survey [20] (2011, as cited in Korovesi, 2016:98). In the same year, McKinsey and Company’s research in Athens, titled ‘Greece 10 years ahead’ [21] (2011:70–71), emphasized that Greece, while positioned to be a significant player in the rapidly growing medical tourism market, lacked a comprehensive national development strategy for this sector. Notably, only a few medical facilities in Greece held accreditation from the Joint Commission International (JCI), unlike numerous facilities in other countries, such as Turkey and Italy. This demonstrated that Greece’s medical tourism industry was underdeveloped, with only a few private Greek clinics offering such services [22]. Another study, the “Development of Medical Tourism in Greece” (2012) by the Institute of Social and Preventive Medicine [23] of the Hellenic Chamber of Hotels [24], argued that medical tourism presented an opportunity for Greece, a country with the potential to excel in this domain. The study highlighted the need for clear development goals and the implementation of a national strategy. In 2014, Greece gained recognition in the field of health tourism, ranking 18th out of 85 countries for the range and quality of medical services offered, demonstrating a substantial increase in the number of hospitalizations. According to the same study, Greece was ranked 14th among the best destinations in a five-year projection in terms of the number of patients expected to visit the country, surpassing countries like Poland and Brazil (Medical Tourism Climate Survey, 2014, as cited in Korovesi, 2016:99) [20]. In 2019, Greece held the 25th position in the medical tourism market, representing 0.4% of the total inbound tourism expenditure, according to a study by the World Travel and Tourism Council (WTTC). Additionally, the country was ranked 34th out of 46 nations, as indicated by the Medical Tourism Index (MTI). The MTI evaluates countries’ performance in medical tourism by assessing the health and tourism industries, along with the overall environment of the host country, with a focus on ensuring the sustainability of medical tourism services. Recent years have witnessed Greece making strides in promoting sustainable medical tourism services. Notably, the country was absent from the MTI list until 2016. Greek studies underscore the favorable factors contributing to its potential as a medical tourism destination, citing the climate, natural and economic environment, modern tourist infrastructure, and high-quality hospitality and health services. The medical services garnering the most attention and popularity include those specializing in fertility, dialysis, orthopedic surgery, ophthalmology, dentistry, aesthetics, rehabilitation, and recovery. By 2021, the health industry emerged as one of the most dynamic sectors in the Greek economy, constituting 9.7 percent of the Gross Domestic Product (GDP) ^[11][12][15][11,12,15]. In addition, empirical research by Theofanides and Papanikolaou [22] underscored that medical tourism in Greece was notably underdeveloped, with only 22 out of 270 private IVF and plastic surgery clinics engaged in providing these services. This underdevelopment was primarily due to several factors: (a) The lack of effective networking between Greek private medical units and intermediaries, such as domestic and foreign travel agents, foreign doctors, foreign clinics, and insurance companies. (b) Inadequate promotion of Greek medical facilities in foreign markets. (c) The absence of specific international certification for health organizations, with most Greek medical units holding general ISO certifications. (d) Minimal support and financing from the Greek state. (e) A lack of strategic orientation, both from the private and public sectors, with insufficient long-term planning and foreign market analysis. (f) A challenging business climate exacerbated by Greek political and economic instability, ongoing changes in tax legislation, and bureaucratic impediments affecting investments. Moreover, a notable concern was the absence of a well-structured and government-funded aid program [24]. Despite these challenges, a study by McKinsey and Company (2011) [21] highlighted Greece’s comparative advantage over other European Member States in this specialized sector. Particularly in the context of the economic crisis, medical tourism could emerge as a lucrative industry. The study estimated that within a decade (2012–2022), medical tourism could contribute EUR 450 million annually to the Greek economy and create 11,000 new jobs. Additionally, Greek medical tourism could gain market share in Russia, the Balkans, the Middle East, selected European countries, and the UK. Cyprus, Turkey, Malta, and Bulgaria were identified as direct competitors to Greece in the field of medical tourism ^[6][25][26][6,25,26]. Greece, known as one of the world’s top tourist destinations, could capitalize on its reputation by expanding its medical services. This could involve blending first-class hotels, natural beauty, ancient and medieval attractions with advanced medical services, and experienced doctors. This opportunity was well-received, as 50% of respondents in a survey expressed an intention to expand medical tourism services in Greece [22]. Similarly, a scientific survey conducted nearly a decade later found that 69.9% of respondents believed that Greece had the potential to become a popular medical tourism destination, indicating substantial growth in the industry, at least until the onset of the COVID-19 pandemic. Additionally, a positive correlation between age and tourism behavior was revealed through data analysis, with younger patients being better informed about medical tourism compared to older ones [23]. Cosmetic surgery emerged as one of the most popular services offered by Greek medical units, as it was easier for patients to associate it with recreational tourism. Rehabilitation and dialysis centers also experienced consistent demand, likely because Greece’s infrastructure in these areas was well-suited for these services. Conversely, services related to eye care, cardiovascular treatments, and IVF showed lower demand ^[22][27][22,27]. According to other estimates ^[23][28][29][23,28,29], medical tourists primarily sought orthopedic, oncological, aesthetic, cardiology, neurological–neurosurgical treatments, as well as fertility procedures in Greece. These medical tourists were typically aged between 45 and 55, had medium to high incomes, stayed for an average of seven days, and were accompanied by a companion. Their average spending during their visit, including their companion, was approximately EUR 5000, significantly higher than the average tourist’s spending of EUR 1500 for the same duration. A study by Intuition (2014) [22] suggested that visitors from Greece’s top four countries of origin had unmet health needs, indicating potential for medical tourism due to factors like economic barriers, wait times, and geographical constraints. Notably, there was a rapid increase in the demand for in vitro fertilization (IVF) in Greece between 2012 and 2016, making it a notable reference center for medical tourism ^[10][30][10,30]. Furthermore, the most common complementary services included partnerships with hotels for accommodation beyond the treatment period [22]. In contrast, there was less demand for services involving cooperation with travel agencies or hosting close family members. Notably, all the Greek medical units in the sample advertised through the Internet, but not all had organized advertising campaigns in foreign markets. Furthermore, only one in ten medical units cooperated with foreign intermediaries. This contrasted with the view presented by Spasojevic and Susic [31], which underscored the importance of intermediaries for the development of medical tourism and as a link between foreign patients and Greek medical facilities. In summary, the evidence suggests that Greece’s efforts in the medical tourism sector are still in their early stages. While neighboring countries such as Turkey are already reaping the benefits of the medical tourism market, Greece is, for the most part, on the fringes of this global development [31].

2.1. Region of Central Macedonia

2.1.1. Demographics

Central Macedonia, Greece’s largest northern region, spans 18,811 sq. km, with a population of 1,792,069. It includes Thessaloniki, Serres, Katerini, Veria, and Giannitsa. Bordering North Macedonia and Bulgaria to the north, it shares boundaries with Eastern Macedonia, Thrace (east), Western Macedonia (west), and Thessaly (southwest). The region boasts flat terrain, many rivers, and economic development in agriculture and industry. Olympus, Greece’s highest mountain, stands at 2918 m. Thessaloniki serves as a key gateway to the Aegean and Balkans. The region features continuous, sandy coastlines suitable for water sports. The climate exhibits notable temperature fluctuations, with January and February as the coldest months and July and August as the warmest. Rainfall occurs in autumn, early winter, and spring, with mountainous regions experiencing colder winters and coastal areas displaying milder Mediterranean climates ^{[23][32][33][34]}[23,32,33,34].

2.1.2. The 15 Thermal Springs in the RCM

In 2017, Deputy Governor Mr. Thanos reported a rising tourist influx in Central Macedonia, emphasizing spa tourism. There are 15 thermal springs. Spa tourism, a key part of health tourism, now attracts a wider range of visitors, including younger, educated individuals, not just for treatment but also for relaxation. Mr. Kouskoukis, a dermatology professor and president of the Hellenic Academy of Spa Medicine, highlighted Greece’s natural healing springs but stressed the need for modern health resorts and infrastructure investments to tap into the global health tourism market, particularly MediSpa services, where Greece can play a prominent role ^[23][35][36][23,35,36].

2.1.3. The Health Sector in Greece and the Position of RCM

Greece’s healthcare system, strained by economic turmoil, prompted reforms. Hospitals are central, with 45% private and 65% public beds, notably concentrated in Attica and Central Macedonia [37]. Greece boasts a high doctor-to-population ratio but low nurse numbers, and brain drain affects medical staff [38]. Recent data indicate that RCM ranks second in doctors after Attica, a potential boost for medical tourism [39]. In a 2019 census of clinics, RCM had 16% of Greece’s clinics ^[39][40][39,40]. Furthermore, RCM is second in the healthcare sector ^[37][41][37,41]. Thessaloniki’s strategic location, infrastructure, and medical resources offer potential for medical tourism [42]. In 2020, RCM received EUR 40 million for healthcare infrastructure [43]. It is noteworthy that the ‘Papageorgiou General Hospital’ in Thessaloniki is a non-profit legal entity operating under private law, providing a wide range of services, including prevention, diagnosis, treatment, and rehabilitation. Moreover, positive developments in 2021 included plans for a new oncology hospital in Thessaloniki [41]. These factors could enhance the prospects for medical tourism in the region.

2.1.4. The Private Health Services Sector

ICAP’s research in 2006 highlighted the robustness of Greece’s private healthcare sector, with ongoing rapid growth. The 2018 study focusing on private health units indicated a recovery in 2018 after five years of recession, citing a 1.5% increase in total revenue. This resurgence was notable despite challenges posed by fiscal adjustments and reorganization in the sector [44]. However, the market experienced an 8% contraction in 2020, attributed to the COVID-19 pandemic [45]. This global health crisis spurred collaborative efforts in the innovation system, enhancing the Health sector’s development prospects worldwide and in Greece [46]. Notably, the RCM, particularly Thessaloniki, hosts advanced healthcare facilities. The ‘Interbalkan Medical Center’ stands out as Southeast Europe’s largest modern private hospital, offering comprehensive medical services, advanced technology, and over 800 staff members. Another significant player, the Euromedica Group, operates an extensive network of primary and secondary care facilities, including diagnostic centers, private clinics, assisted reproduction units, and rehabilitation centers across Greece, notably in Thessaloniki (Euromedica Group website).