Journal of Hospitality and Tourism Insights

Why medical tourists choose Turkey as a medical tourism destination?

Ilhan Sag, Ferhat Devrim Zengul,
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Ilhan Sag, Ferhat Devrim Zengul, (2018) "Why medical tourists choose Turkey as a medical tourism
destination?", Journal of Hospitality and Tourism Insights, https://doi.org/10.1108/JHTI-05-2018-0031
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Turkey as a
Why medical tourists medical
choose Turkey as a tourism
destination
medical tourism destination?
Ilhan Sag
Department of Marketing, Anadolu University, Eskişehir, Turkey, and
Received 25 May 2018
Ferhat Devrim Zengul Revised 23 July 2018
31 August 2018
Department of Health Services Administration, University of Alabama at 13 September 2018
Birmingham, Birmingham, Alabama, USA Accepted 17 September 2018

Abstract
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Purpose – The purpose of this paper is to determine the relationships between the health tourists’
perceptions on decisive factors (i.e. experience, technological infrastructure, flight distance, legal and moral
restrictions, touristic attractions, religious similarity, waiting time and price of health tourism) and Turkey as
their choice of healthcare tourism destination.
Design/methodology/approach – The data for this empirical study were collected from 288 patients in
Turkey, all of whom being health tourists from various countries. Descriptive statistics and Kruskal–Wallis
difference tests were utilized for analyses.
Findings – Statistically significant differences were found among health tourists in regards to the
geographical regions of their residence. These finding suggest that differences among health tourists in
regards to the geographical regions of their residence contributed to the healthcare tourists’ behaviors and
health tourism market segmentations in Turkey.
Research limitations/implications – Among the constraints of the study are the time and funding
limitations coupled with the limitations on the scale development attempts in the health tourism literature and
limitation and biases related to primary data collection. Despite all these limitations, by being the first study
exploring the health tourism market segmentations in Turkey, this study contributes to the literature about
the perceptions of health tourists and their reasons in choosing Turkey as a health tourism destination.
Practical implications – Determining the Turkey’s health tourism market segmentations will generate the
positive effect on the target market which is currently heterogeneous for health tourism operators and
intermediary institutions. Moreover, this knowledge would allow the target market to be divided into
homogeneous groups, with different marketing mixes for each group. Homogenized groups exhibit unified
purchasing behaviors for their needs. Therefore, it is very important for health tourism operators and
intermediary institutions to know how the preferences of health tourists from different geographical regions vary.
Originality/value – The paper fulfills a need for advancing the knowledge on the decisive factors in
determining Turkey as the health tourism destination by revealing perceptions of health tourists from
various geographical regions. This information is very valuable for the Turkey’s healthcare tourism
marketing managers who desire to implement the strategies to achieve competitive advantage in the global
health tourism market.
Keywords Competition, Destination choose, Healthcare and medical tourism
Paper type Research paper

Introduction
Recently, there has been a growing interest in medical tourism, mainly due to its potential
positive impact on the economy of the destination country (Drinkert and Singh, 2017;
Erfurt-Cooper and Cooper, 2009; Fuchs and Reichel, 2010). Tourism, in its classical sense, is
defined as “traveling to another country from country of origin for entertainment purposes”
(Karaküçük, 2014). Health, on the other hand, is defined by the World Health Organization
as “not only the absence of disease or disability but the complete well-being of the person
including both physical and mental dimensions” (WHO, 2017). Combined, medical tourism
refers to traveling to another country for touristic and health reasons with a primary reason Journal of Hospitality and Tourism
Insights
being the health. Health and tourism concepts complement one another and have gained © Emerald Publishing Limited
2514-9792
momentum with the increase of the economic incomes of the world nations, elderly DOI 10.1108/JHTI-05-2018-0031
 JHTI population, transportation capabilities and internet marketing (Drinkert and Singh, 2017;
Smith and Forgione, 2007). Medical tourism, generally used interchangeably with health
tourism, is offered as an innovative product by tourism and healthcare professionals
(Cannon Hunter, 2007). It is seen as an alternative tourism generated by combining tourism
services (e.g. hotel management, accommodation transportation, and marketing) with health
and rehabilitation services (e.g. medical intervention, surgery, spa, wellness, thermal and
herbal treatment) (Tontus, 2015). This new and niche industry (Cannon Hunter, 2007; Cetron
et al., 2006) has a high potential of making an enormous impact on the economic and social
life of countries, especially developing ones, which cannot afford to neglect such a growing
possibility (Cannon Hunter, 2007; Heung et al., 2010).
Although the most preferred developing countries in medical tourism are India, Cuba,
Costa Rica, Thailand, Singapore, Colombia, and Malaysia (Aksu et al., 2016), Turkey has the
potential to become one of the leading medical tourism destinations in the world. This
potential is primarily due to the recent health transformations and investment reforms,
which are increasing international tourism performance, and low-cost services.
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Additionally, the availability of well-educated health personnel, technological

infrastructure, climate diversity, natural beauty, and historical richness makes Turkey an
attractive medical tourism destination (Aksu et al., 2016). However, there are some
challenges for the medical tourism sector in Turkey (İlban and Kaşli, 2009; Ozsarı and
Karatana, 2013; WTTC, 2018). One of them being the hospitals’ and tourism companies’
insufficiency in entering and managing the operations of the medical tourism market (Aslan
et al., 2014). This newly developing industry in Turkey (Abubakar and Ilkan, 2016;
TUROFED, 2017) lacks the strategic marketing roadmap, which includes the development
of market segmentation with the proper marketing mix (Barca et al., 2013; Tengilimoğlu
et al., 2014; Tontus, 2015). In the light of all these challenges, medical tourists’ behaviors gain
importance as a consumer because it enhances the competition among countries like
Turkey. Therefore, understanding the role of various reasons for medical tourists in
choosing Turkey as a medical tourism destination is crucial for the development of such a
strategic marketing roadmap (TUROFED, 2017).
The purpose of this paper is to determine the relationships between the medical tourists’
perceptions on decisive factors (e.g. previous experience, technological infrastructure, flight
distance, legal and moral restrictions, touristic attractions, religious similarity, waiting time
and price of medical tourism) in choosing Turkey as their medical tourism destination.

Lıterature
Medical tourism can be defined as people traveling abroad to receive treatment from a
location where they reside in (Ross, 2001). More specifically, medical tourism is defined
as organizing trips to places where individuals can receive health care (e.g. medical
intervention, surgery, SPA, wellness, thermal and herbal treatment, etc.) to protect or
improve their mental and physical well-being (Carrera and Bridges, 2006). These individuals
who travel for medical tourism are called health or medical tourists (Gyu Ko, 2011). Based
upon their purposes, these medical tourists can be defined in four categories:
(1) dedicated – has a pre-determined treatment plan and traveling mostly for treatment;
(2) hesitant – decide on the treatment options after arriving at the medical tourism
destination yet traveling primarily for treatment;
(3) holidaying – has a pre-determined treatment plan, however, traveling mostly for
pleasure; and
(4) opportunistic – decide about the procedure after arrival and traveling primarily for
pleasure (Wongkit and McKercher, 2013).
 Historically, the earlier forms of medical tourism were introduced at the spas (selus per Turkey as a
aqua) in the eighteenth century within tourism services in the form of feeling better and medical
improving health. In later years, therapy, recreation, yoga, and meditation were added tourism
(Connell, 2006). Today, global medical tourism is a $55 bn industry with a projected annual
growth rate of 20 percent (Sandberg, 2017). Each year, approximately 11 m people travel destination
abroad for health care, and in 2017, 1.4 m of these medical tourists were Americans seeking
health care outside the USA according to the Patients Beyond Border (PBB, 2018).
As shown in Figure 1, the top medical tourism destinations include Costa Rica, India,
Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey, and the USA
(PBB, 2018; Sandberg, 2017). Each location offers different products (e.g. cosmetic surgery,
dentistry, cardiovascular, orthopedics, cancer types, nanotechnology, reproductive health,
weight loss, diagnostic scans, tests, health screenings, and second opinions) for distinct
markets (Sandberg, 2017). For example, the USA and Cuba offer plastic surgery whereas
Thailand provides eye surgery, kidney dialysis and organ transplantation (Cannon Hunter,
2007). By being at the intersection of three continents with many transportation options,
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Turkey is one of the important destinations (Cannon Hunter, 2007). Approximately 500,000
medical tourists receive health care in Turkey annually, generating $2.5bn in 2013 from
cardiovascular, esthetic surgeries and eye diseases (TURSAB, 2017). In 2017, more than
1mn people came to Turkey for health tourism and provided more than $10bn of foreign
currency inflow to Turkey. Aesthetics and hair plantation was at the forefront of the
services that the medical tourists received. Medical tourists visited Turkey from Saudi
Arabia, Kuwait, Qatar, United Arab Emirates, Germany, the UK, the Netherlands, Italy,
Spain, and France (AA, 2018).
The touristic attractions and destinations can be considered as one of the essential factors
in choosing a particular country for medical tourism (Fetscherin and Stephano, 2016).
A country develops its medical tourism industry in two ways. First, medical tourists evaluate
potential destinations based on pre-developed judgment or their previous experiences.

Figure 1.
Leading countries
promoting medical
tourism
Source: Adopted from PBB (2018); Sandberg (2017)
 JHTI For instance, if medical tourists are exposed to negative communication/news about incidents,
wounds, and health-related events in the past, this negatively affects the experience or
perceptions of tourists in selecting a particular destination. Some countries are promoting and
investing in medical tourism to develop the tourism industry further. These countries are
evaluating whether these efforts will increase both the number of tourists and the income
earned from medical tourism (Lee, 2010).
Today, the world population has more capability economically and logistically than past
centuries. As a consumer, today’s world population is looking for new and different
destinations for travel and holiday experiences. These consumers are much more sensitive
to other aspects of a marketing mix such as location, destination, privacy, quality than
prices (Garcia-Altes, 2005). Medical tourists who participate in medical tourism exhibit
consistent behavior, like intrapersonal processes originating within the individual during
their decision-making processes. Medical tourists evaluate many factors, such as the content
of the products and services presented, the urgency of decision making, alternatives, the
quality of care at the destination and perceptions about the destination before deciding upon
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the final destination (Aksu et al., 2016).

Hudson and Li (2012) mentioned that political stability, accreditation of facilities, accessibility
and country brand could be considered among the decisive factors (i.e. the motivators that are
important in choosing specific destinations during the decision-making process) of the supply
side in medical tourism. Low cost has been pointed out as another primary reason for patients
from industrialized nations to have medical services in less developed countries (Horowitz et al.,
2007; Marlowe and Sullivan, 2007). According to Lunt et al. (2010), clinical quality, safety and
other performance criteria that support informed decision-making can be considered as critical,
decisive factors for medical tourists. In a study that used the theory of planned behavior to
investigate the medical tourist’s beliefs on the availability of quality healthcare, highly trained
competent doctors and the ability to vacation and visit another country was identified among
factors that promote travel for medical treatment (Reddy et al., 2010).
Figure 2 exhibits a two-stage model that indicates the factors that influence a patient’s
decision to seek health-care services abroad. The first stage includes country factors,

Country Factors Medical Facility Factors

Political
Hygiene Costs
Climate

Touristic Physician
Attractions Training
International Medical
Country Facility
Location Location Quality
Economic
of
Condition
Care

Figure 2.
Factors that affect the Regulatory Country Services
choice of medical Accreditation
Policies Image cape
facilities and
destinations
Source: Adopted from Smith and Forgione (2007)
 such as economic conditions, political climate, and regulatory policies. The second stage Turkey as a
comprises medical facility factors, such as costs, physician training, quality of care and medical
accreditations. Based on this model, medical tourists select a destination by taking into tourism
consideration both country and medical facility factors (Smith and Forgione, 2007).
Caballero-Danell and Mugomba (2007) also developed a framework that links consumers destination
to destinations through three distribution channels: operators, representatives within the
target consumer markets, which are also referred to as intermediaries and word of mouth
(see Figure 3).
Heung et al. (2010) suggest in their conceptual work that medical tourism should be
investigated by using quantitative methods to understand medical tourists’ choice of
destinations. Despite the importance of the healthcare at the destination, studies have not
gone deep enough to investigate the medical tourism industry in Turkey, especially in
regards to the destination preferences of medical tourism patients. The present study aims
to fill this gap by exploring the medical tourists’ country of origin and the decisive factors
that led them in deciding Turkey as their medical tourism destination.
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Method
A descriptive model was used in this study. Research data were collected using a
questionnaire based on a measurement instrument initially developed by Moghimehfar
and Nasr-Esfahani (2011). The scale of the medical tourist destination of Moghimehfar and
Nasr-Esfahani’s (2011) was adapted and improved by utilizing expert opinion and literature
review. The new scale has seven items. The original scale which was in English has been
translated into Turkish, French, German, Persian, Arabic, and Russian with test–retest
technique. Patients were asked to answer five-point Likert scale questions. Ethics committee
approval was received from the Expertise and Training Committee of the University of
Health Sciences Ankara Abdurrahman Yurtaslan Educational Research Hospital on
January 1, 2017, for the implementation of the study. A research authorization was also
obtained from the Turkish Ministry of Health, and the pilot study was performed by using
convenience sampling. Survey instruments were distributed via e-mail to ten hospitals
where approximately 350 medical tourists were receiving care. These ten hospitals
included four government and six private sectors and spread across the seven largest cities
in Turkey, including Ankara, Istanbul, Adana, Antalya, Denizli, Erzurum, and Izmir.
With the help of nurses and hospital managers, 288 survey instruments were completed.

• Medical tourism operators

• Accessibility
• Online Communications
Customer
• Representatives in the customer’s Destination
(patient)
country
• Word of mouth
• Subjective Norms

Fıgure 3.
Distribution channel
model
Source: Adopted from Caballero-Danell and Mugomba (2007); Hudson et al. (2017)
 JHTI Therefore, with a response rate of 82 percent, the final study sample includes 288 patients,
all of whom were medical tourists from various countries. The validity of the survey
instrument was assessed and confirmed by expert opinion and the literature. The reliability
of the survey instrument was evaluated and confirmed by Cronbach’s α of 0.705. This score
is almost the same as the original scale (0.725) (Moghimehfar and Nasr-Esfahani, 2011).

Findings
Survey respondents (Table I) included patients from the following regions: 39.5 percent
Middle East, 31 percent Europe, 7.9 percent Eurasia, 7.6 percent Balkans, 5.9 percent
America-Australia, 5.2 percent Middle Asia, 2.4 percent Africa. The two largest groups of
medical tourists in the sample were from the Middle East and Europe.
Table II exhibits the Kruskal–Wallis difference tests between the medical tourist
destination choice and the geographical regions that the patients are traveling from. As a
non-parametric test, Kruskal–Wallis was the most appropriate since the underlying data was
not normally distributed and was from surveys that were based upon five-point Likert scales.
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According to Kruskal–Wallis difference tests (Table II), statistically significant differences

( po0.000) were found among medical tourists in regards to the geographical regions of their
residence. For instance, the low medical treatment prices in Turkey are more critical for
medical tourists from Eurasia, the Balkans, and Central Asia, than Europe, America, and the
Middle East. Patients from the Balkans, Central Asia, and Middle East countries prefer
Turkey because of the highly trained doctors and well-equipped hospitals compared to their
own countries. However, this was not observed among patients from Europe, America-
Australia, and Eurasia countries. Patients from Central Asia, the Middle East, and Balkans
prefer Turkey, due to legal and moral restrictions in their country of residence. It appears that
patients from Europe and America-Australia are not affected by the legal and moral
restrictions in their countries. The tourism mobility of Turkey positively impacts patients
from Central Asia and the Middle East – Turkey. Unlike the expectation and general literature
about longer waiting times in European and American countries, patients from countries
other than Europe or America visit and prefer Turkey due to the decreased waiting times.

Discussion and conclusions

Conclusions
This study aims to reveal the decisive factors of medical tourists in choosing Turkey as their
medical tourism destination. Among the findings, there were several highly significant results.
First, lack of expertise or technologic devices in the home country of the medical tourist was
the most crucial factor in choosing Turkey for medical tourist from Balkans and Middle Asia
than the other regions, particularly Europe and America-Australia, given the technological
development levels of these specific regions. In this paper, we used flying distance as a
criterion to combine small numbers of observations in specific geographical locations,

Regions Number of persons Percentage

European 90 31
Balkans 22 7.6
Middle Asia 15 5.2
Eurasia 23 7.9
Africa 7 2.4
Table I. Middle East 114 39.5
Participants’ America-Australia 17 5.9
characteristics Total 288 100
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Mean rank
Regions
Middle Middle America-
Questions European Balkans Asia Eurasia Africa East Australia χ2 Sig.

Q1: My destination choice was affected by the distance between my home

country and Turkey 130.97 198.18 168.6 150.85 124.29 147.6 142.41 9.768 0.135
Q2: My destination choice was affected by the low price of medical treatment
in Turkey 139.9 180.98 186.43 183.17 97.5 136.81 139 17.35 0.008*
Q3: My destination choice was affected by lack of expertise or technologic
devices in my home country 116.77 192.3 212.17 147.63 117.71 151.54 141.5 30.089 0.000**
Q4: My destination choice was affected by legal or moral restrictions in my
home country 124.95 160.02 197.33 125.93 95 159.82 134.44 20.502 0.002*
Q5: My destination choice was affected by the tourist attractions of Turkey 118.92 143.8 183.17 136.72 167.57 164.08 126.47 20.828 0.002*
Q6: My destination choice was affected by the religious similarity of my faith 102.83 164.39 181.43 117.98 152.86 178.19 122.21 6.683 0.192
Q7: My destination choice was affected by long waiting time in my home
country 131.07 162.86 152.37 117.41 151.36 156.07 141.15 38.854 0.000**
Overall: Total reason of destination choice 105.44 169.86 209.03 125.63 109.79 157.75 119.03 38,854 0.000**
Notes: *Sig.o 0.01; **Sig. o0.001
tourism
medical

destination
Turkey as a

difference tests

patients resides
where the
geographical regions
choice and the
between the medical
Kruskal–Wallis
Table II.

tourist destination
 JHTI such as America and Australia. However, this finding should be approached carefully since
the percentage of medical tourists from the Balkans and Middle Asia was low compared to the
Middle East and Europe. Therefore within the significant findings, the most reliable and
generalizable results would be the difference between the Middle East and Europe. In line with
this inference, when medical tourists from the Middle East and Europe are compared we see
that lack of expertise or technologic devices (Q3), legal or moral restrictions (Q4) and long
waiting time in the home country of medical tourist, as well as the tourist attractions of
Turkey (Q7), are more important for medical tourists from the Middle East than the ones from
Europe. Among all significant results only Q2, which suggest the low price of medical
treatment in Turkey as an important factor was slightly more important for European than
Middle Eastern medical tourists.

Theoretical implications
The theory of planned behavior suggests there are three types of beliefs that guide human
behavior: behavioral, normative, and control (Ajzen, 1985, 1988, 1991). In the case of
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behavioral beliefs, one would consider the likely consequences of a particular behavior, in
the normative beliefs one would seek for the normative expectations of other people and
lastly in control beliefs existence of certain factors may inhibit performance of a behavior
(Ajzen, 1985, 1988, 1991). In our study, it seems that during decision-making processes
medical tourists have utilized various combinations of these beliefs. Analyses indicated
several significant differences among the medical tourist from different geographical
regions and the factors affecting their choice of a medical tourism destination. Findings of
this research confirm the conclusions of the some of the earlier works (Horowitz et al., 2007;
Marlowe and Sullivan, 2007; Lunt et al., 2010; Reddy et al., 2010; Hudson and Li, 2012).
Similar to the earlier studies, low cost is one of the primary reasons for patients from
industrialized nations to have medical services in less developed countries. Moreover, the
availability of quality healthcare, highly trained competent doctors, and the ability to
vacation and see another country was also identified among factors that promote travel for
medical treatments as seen in the theory of planned behavior. Furthermore, clinical quality,
safety and other performance criteria that support informed decision-making can be
considered as critical, decisive factors for medical tourists.

Practical implications
The findings of this study have several significant practical implications. First, the insights
gained about the current composition of medical tourists regarding their country of origins,
and their preferences would be useful in developing country-level short-term and long-term
strategies for Turkey. It has become imperative for Turkey to create new marketing strategies
and promotional tools to protect and improve its share in the world medical tourism market,
due to the intensifying competition. The ever-increasing competition in the tourism industry
among the world countries and increasing healthcare cost in developed countries, such as the
USA, places medical tourism in a strategic position for Turkey. As a unique sector that
combines tourism and health, medical tourism has a potential to generate the much-needed
competitive advantage for Turkey, by harnessing its strengths in both tourism and health
care. From this perspective, by exploring the existing medical tourists and the variation in
their preferences, which are based upon their geographical locations, this study provides the
insights to the Turkish tourism ministry and private industry. These insights would allow the
development of targeted promotional activities for different geographic segments of medical
tourists. Knowing what kind of health services are desired by medical tourist from a particular
geographical location and why these tourists seek care in Turkey, enables the development of
such targeted strategies that would lead to a higher quality and more personalized services.
As the study results suggest, while developing promotional materials to attract European
 medical tourists, the affordable prices in Turkey can be emphasized. On the other hand, Turkey as a
promotional materials for medical tourists from the Middle East may benefit from medical
emphasizing more on high technology services and high skills of medical personnel in Turkey. tourism
Second, it is also essential to know the geographical characteristics and sensitivities
among medical tourists toward the services that they receive. Medical tourists tend to have destination
a high sensitivity of demand toward the desired procedure, mainly due to the external
factors. Achieving a stable and increasing trend in demand requires a better understanding
of geographical variations and preferences of medical tourists. Such an approach would lead
to the development of the existing market into segments and different medical tourism
products, along with services that are targeting these different segments. As the results
suggest medical tourists from the Middle East tend to have higher sensitivity about legal
and moral restrictions, as well as the long waiting time in their home country compared to
the tourists from Europe. Exploring the underlying reasons for such sensitivities would
allow the development of strategies to generate steady and increasing demand from these
particular geographical regions.
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Third, determining Turkey’s medical tourism market segmentation will generate the
positive effect on the target market, which is currently heterogeneous for medical tourism
operators and intermediary institutions. Moreover, this knowledge would allow the target
market to be divided into homogeneous groups, with different marketing mixes for each
group. Homogenized groups exhibit unified purchasing behaviors for their needs. Therefore,
it is crucial for medical tourism operators and intermediary institutions to know how the
preferences of medical tourists from different geographical regions vary.
Fourth, the insights gained from this study about the target market and the consumer,
namely the medical tourists, would be precious to the marketing managers, due to the
following reasons: this knowledge would allow the development of strategies that would
reduce the uncertainty about the demand for medical tourism; understanding the differences
and preferences of medical tourists would also allow a better-informed decision-making
process; and the gained insights from this study would be useful in exploring new
opportunities for improving medical tourism in Turkey.

Limitations and future research

Among the constraints of the study are the time and funding limitations coupled with the
limitations on the scale development attempts in the medical tourism literature. There could
also be a potential limitation and biases related to primary data collection. For example, due to
time and funding constraints, we were not able to follow up with non-responders. Despite all
these limitations, we achieved a 82 percent response rate and drew valuable insights about the
medical tourism in Turkey. Considering the limited number of research on medical tourism in
Turkey and the limitations of the current study, there is definitely a need for future studies.
Our recommendations for future studies are summarized in the following points. First, a
potential future study may explore demographics of medical tourists along with the
healthcare procedures that the medical tourists are seeking in Turkey. Second, another
prospective study may investigate the types of legal and moral restrictions and their
implications on medical tourists’ destination preference. Third, even though our study
collected data from ten hospitals in the seven largest cities in Turkey, a more representative
study that includes higher numbers of hospitals and medical tourists would be beneficial to
develop conclusions that are more generalizable. Finally, another potential study may
explore the financial implications of medical tourism on the preferences of different medical
tourist categories (e.g. procedure type, geographic regions, age groups, and gender).
In conclusion, by being the first study to explore the medical tourism market segmentation
in Turkey, this study contributes to the literature about the perceptions of medical tourists
and their reasons in choosing Turkey as a medical tourism destination.
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Corresponding author
Ilhan Sag can be contacted at: ilhansag@anadolu.edu.tr

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