Low-Cost Health/Medical Tourism of Italians

In recent years, becoming a form of spatial mobility of people is mainly called “medical tourism or health tourism”. In Italy the adoption of the expression “turismo sanitario” is often used as an international expression synonymous with “medical tourism or health tourism”: this situation raises a number of conceptual problems. In fact, the Italian public health service is one of the most developed in the world and is distinguished by many nations to the fact to offer its citizens free of charge and many health care services. In this situation, the Italian citizen in need of medical care is not convenient to travel to other places and is not obliged to do so. In fact, the Italian citizen tends to move for medical and health care that the Italian public health service does not deliver at no charge: such as dental care, we will deal with this case illustrating some examples of dental tourism low cost of the Italians. However, from our point of view, tourism period may be coupled to the trips to the health or well-being only in cases where the journey is “voluntary.” All this will be discussed in this paper.


Introduction
Expressions like medical tourism or health tourism are very widespread nowadays and for the past 10 years are used to indicate the geographical (territorial) mobility of people moving around the world looking at this way of meeting together the motivations and needs that deal with health and well-being, with needs related recreation, knowledge, and holidays. This kind of mobility has grown more and more over time due to the (considerable) opportunity of visibility by World Wide Web about global health opportunities. In fact, due to World Wide Web, people have the possibility to communicate in real time and the ability to move faster and faster and economically in space, especially through low-cost air transport.
In the contest of health and wellness, there is a real competition between touristic destinations that are increasing their product offerings in order to gain significant shares of this type of tourism market.
However, within the analysis and study of the phenomenon, the first difficulties refer to the theoretical and conceptual problems it generates, especially in the Italian case, the use of the term "health tourism." In this work, we will analyze this particular issue and the low-cost medical tourism of Italians. 1 It is favorable to point out that in Europe we have tried to regulate the sector of health services with specific European directive of 2011, 3 establishing the rules for cross-border healthcare, under which European citizens are now allowed to cure themselves freely even in countries other than their own.
In any case, what our opinion appears at this point is necessary that it is to reflect on at least two issues. The first one is whether expressions indicating the so-called "medical tourism" indicate the same phenomenon, even if with different shades, at the international level; the second one is if the mobility of people determined to respond to medical and health needs is in fact appropriate to pair the word "tourism." Regarding the first question, there is to say that, in the "literature," this kind of tourism is almost always considered substantially equivalent to those of Anglo-Saxon term of "health travel," "medical tourism," or even "Health & Medical Tourism." 4 In fact, however, this situation seems to represent a simplification not useful to understand the differences.
For example, in the Anglo-Saxon world, we are faced with health services, in many cases, paid services and that's why you go looking for economically viable healthcare solutions; this situation assumes the possibility of physical movement, and in these cases, for the same quality of medical service, the choice of where to go can also depend on the attractiveness of the tourist places and/or of the availability of tourist services and leisure. In the Italian case, however, even if a national health service exists, the prevailing gratuity brings the citizen to move to different places than those in which he lives only in the case of particular services or nonexistent or poors at the local level.
In short, from a substantive point of view, the Italian expression "turismo sanitario" does not have the meaning exactly similar to those attributed to the expressions used in the international arena such as "health travel" or "medical tourism." Therefore, in our opinion not even conventionally, in the case of the Italian medical tourism, it appears appropriate to use dogmatically such an expression to propose a comparison with other international experiences, particularly with Anglo-Saxon ones, where, unlike the Italian system, the health services are of private nature, and for that, they are a substantial economic burden to the citizen.
The second issue on which we have set ourselves to reflect on it is whether it is in fact appropriate to use the term "tourism" to indicate the physical mobility of people toward health services, which is currently widespread.
Indeed, technically the use of the term "health tourism" depends by the definition of tourism generally adopted, developed, and proposed by the UNWTO, 5 according to which 6 : "Tourism is a social, cultural, and economic phenomenon, which entails the movement of people to 3 For a discussion about the cross-border healthcare scheme, see Ref. [1]. 4 In this regard compares, for example, Refs. [2][3][4]. 5 The UNWTO acronym stands for "United Nations World Tourism Organization"; the corresponding Italian acronym is OMT (Organizzazione Mondiale del Turismo). 6 The tourism definitions provided by the UNWTO are so many, since tourism is a social phenomenon that continually changes its character, the definitions have gradually over time adapted to ongoing social changes. The definition given refers back to 2014 and it is within the "Glossary of tourism terms" UNWTO [5]. countries or places outside their usual environment for personal or business/professional purposes. These people are called visitors (which may be either tourists or excursionists; residents or nonresidents) and tourism has to do with their activities, some of which involve tourism expenditure." In this regard, it is worth to highlight that the definition of tourism over time has greatly expanded its conceptual meaning, and today, there is a tendency, in fact, to consider tourists even those who move for instrumental purposes (for example, for work reasons), and this leads to a census as a tourist movement, practically all types of travelers regardless the motivation that determines the journey.
In other words, to be tourism, to be able to label a particular territorial mobility of people as a tourist, it would be enough for the presence of a condition: the journey to a destination other than the one where you normally live. While visitors/hikers, even if today conceptually considered tourists, they remain statistically and economically very difficult to evaluate due to the absence of at least one night in an accommodation facility.
Anyway, the definition of tourism provided by the UNWTO and with it, a large capacity to consider substantially as tourism, as we have said before, almost all streams of people who move to places other than their own for us is clearly very difficult to recognize as valid the "health tourism" expression; we see a paradoxical situation in part, in the sense that it seems almost an oxymoron. Here, we try to explain what we mean.
Indeed, contemporary society no longer offers the certainties of modernity and even try to frame the conceptual and theoretical point of view of tourism phenomenon, precisely because social phenomenon of globalized mass and in continuous expansion, it becomes an increasingly difficult operation and contains full of obstacles. However, we think to have some certainties.
In a study of sociology on tourism very well-known internationally and still widely used today, Cohen [6] identified and defined the tourism role based on some dimensions. In other words, according to this scholar, any traveler could call himself a tourist in the presence of the following dimensions: (1) the stay of tourists should be temporary (for this reason they are different from other types of travelers as they have a residence that makes them traceable); (2) the tourist makes a round trip (this distinguishes it from the travelers who move to other places, such as immigrants, permanently); (3) the visitor makes a journey that is not completed in the same day (what differentiates it from hikers travelers); (4) the tourist traveling along pathways that, however, do not occur frequently; (5) tourists in traveling do not pursue instrumental goals (what distinguishes it from business travelers, for example, businessmen, missionaries, politicians, etc.); (6) the tourist is a person who decides to embark on the journey in a totally voluntary way (what distinguishes him from all the travelers who become obliged, for example: victims of political persecution, political prisoners, the prisoners, the sick, etc.) [7].
Cohen's work, although of extremely useful and epistemological interest, we have no difficulty in admitting that by virtue of the important changes that have affected the tourism phenomenon in time, it is no longer present and, moreover, "… It is limited in the real tourist experience. A series of figures traveler would remain outside in which the tourism component has ample space. Consider, for example, hikers, those who decide to spend a day on a farm or under an umbrella at the beach, or even the congressman who takes the opportunity to learn about a new location, it is these situations which are now generally considered to be a constituent part of tourist flows." [7].
Even taking into account the above, by comparing the contents of Cohen's tourism dimensions and the definition of tourism role by UNWTO and adopting a more conceptual flexibility; however, it seems to emerge a broad convergence about who the tourist is and what tourism is. So given things, the aspect that even the definition of tourism UNWTO does not capture is "the voluntary nature of the trip." This, in our view, remains central to really understand what tourism is distinguishing it from what tourism is not and who tourist is from who is not even when the journey that is accomplished is not voluntary? Can trips really be included in tourist flows that they are required to do?
Using the definition UNWTO, the answer would be, probably, yes! While in the past, the entire mobility made with mostly recreational purposes and entertainment was considered tourism; today, there is a tendency to see the presence of tourist aspects in all types of mobility, and for that, we can conclude on the basis of over-simplifying phrases such as that included in the definition given above by the UNWTO tourism: Tourism is a social, cultural, and economic phenomenon, which entails the movement of people to countries or places outside their usual environment for personal or business/professional purposes.
Indeed, however, can we really think that a person who is working as a sales representative and that every day, he travels for hundreds of kilometers by car, traveling from city to city, even sleeping and eating at several hotels and restaurants, can be counted as tourist mobility? Or that the person who moves from his home to go to work for 6 months a year in another place and in doing so also sleeps and eats in various hotels and restaurants, can it be counted as a tourist mobility? Or also, and more simply, can it be considered a tourist the parent obligated to visit a university student son in need of help, and in doing so, he spent a short time in a holiday complex located in a distant city? From our point of view, the answer to these questions is probably not! The voluntary nature of the trip remains an essential element of tourism; otherwise, we are talking about something else and not of tourism. 7 Also, since it does not solve the problem of voluntariness of the trip, we think that the simplification of Henderson [8] is not very useful and that it has encouraged the definition of the various areas of "health tourism" dividing the search for cures into four categories: (1) the area of disease conditions (all forms of surgical interventional, diagnostic investigations, etc.); (2) the wellness area that can encompass the so-called alternative medicines as well as spa treatments and fitness; (3) the area of esthetic enhancement through plastic and cosmetic surgery; (4) the breeding area for fertility treatments and assisted reproduction.
Ultimately, based on the principle of voluntariness of the journey becomes really difficult to see if and when it is possible in the Italian case, the use of the term "health tourism," an expression, in our opinion, that to represent the phenomenon is more just separate into two further expressions: "medical trip" and "wellness tourism": • With the "medical trip" expression, we could indicate all those travel experiences that individuals make because in any case obliged, the motivation of the travel to seek health care controls and/or medical treatment that they are necessary to the control or to the resolution of a disease, though the related medical and health care services are available at the place where he usually lives; • With the "wellness tourism" expression, we could, however, indicate all volunteer's trips that people make for not essential medical services but for the care of the psycho-physical wellness of their appearance. Among other things, it is worth noting that in the Italian case, the public national health service does not recognize the costs of nearly all of these treatments, which are therefore the sole responsibility of the citizen, and even if the choice of the medical structure in which "you receive care" is important, it is important too, the identification of the place where to go that sometimes convinces in particular the offer of "tourist" services associated, in other words to mix business and pleasure.
In the first case, that one of "medical trip," we find ourselves faced with a necessary journey, where the only motivation is the need for appropriate treatment, maybe only available in certain cities and medical facilities. Although for these purposes, you may need to go in very desirable locations, or use the magnificent tourist services, it is difficult to think that this kind of travel experience is actually a tourism experience. In the second case, that one of "wellness tourism," are faced with travel volunteers, either because not necessary from a medical point of view or because the health services are generally widespread or available in the places where you live, in any event, services not absolutely necessary for the very survival of the person. Moreover, in the case of "medical trip," the challenge to attract the attention of the person as a "traveler" is not based on the tourist attractiveness of the destination, but on the presence of medical facilities and onto high quality or unique health services (in this case, the choice of where and how to stay will depend more easily by logistical and/ or economic parameters). While in the case of "wellness tourism," not only the choice is based on availability and quality of services and healthcare type structures, but also on the attractiveness of the tourist destination, on the different and qualified availability of tourism services, and reachability of the destination (the most obvious case is that of dental care, where in the last decade has developed an international challenge, with dozens of different offer packages that include in addition to medical care, travel, accommodation, excursions in the area, and an increasingly wide range of additional services for leisure).
In conclusion, we recognize as not useful and misleading using the term "health tourism," at least in the Italian case. The reasoning led us first of all to separate the expression into two parts to start to understand more fully the phenomenon: we think we can establish that the "medical trip" is obligated by its nature, and therefore, it is not considered as tourism, as is the related traveler cannot be considered a tourist but, a "person in need of medical care"; the "wellness tourism" is, however, more properly defined as "health tourism," because the more easily the nature of the trip is voluntary and the ability to care about their psycho-physical wellness reconciles with the tourist experience that assumes knowledge of the places where you are traveling and the development of relations and knowledge relations with host populations. 8

The so-called "health tourism" market
Evaluate the value of world market of so-called "health tourism" is not easy for two reasons.
The first one is a question of conceptual character. As we wrote before, to establish with reasonable accuracy what actually "health tourism" is, it is possible only when you come to a shared definition of the meaning. However, for the purposes of this paper, we assume that health tourism like all mobility that is determined by motives that concern as well as medical care dedicated to the more general welfare of the people. The second reason is the scarcity of systematic studies of this type of mobility, for which you will use what we currently have.
Bearing in mind the considerations just made, we say that already about 10 years ago, the American company Deloitte Research [10] predicted a rosy future for the US health tourism, which it imagined would touch the six million citizens compared to about eight hundred thousand in 2007, for a global turnover estimated at several billion dollars annually.
The same Deloitte [11], in a later study calculated "… that every year seven million people in the world travel because of health reasons, already generating a turnover of 100 billion dollars, which will become 150 in 2018" [12]. In addition, according to another study dated 2016, "… the revenue generated from medical tourism already amounted to 12 billion euro in Europe … Italy has a market share of 2 billion, which could reach 4, by implementing the "provision of health and tourism services offered to foreigners." 9 The so-called health tourism is today a social and economic phenomenon of great importance in fact recently, and for the first time in one of the most important fairs of world tourism, which was the FITUR 2015, a specific space it has been reserved right to health tourism.
However, the Italian Association for Medical Tourism Development (IAMT) has published on its website [13], a brief illustration of the background of health tourism. In particular, the variables that determine the majority of the customer mobility flows are the quality of the delivered treatments; better access to health services; the absence of waiting lists; the ability to bind to a health need for the satisfaction of a tourist needs; travel opportunities; the cost of treatment, which is a significant variable for a given segment of the market; the confidentiality, especially for esthetic interventions. In addition, with regard to the health tourism numbers, it notes that about 15 million tourists patients in 2017 will decide to resort to medical treatment abroad, and that the major destinations of health tourism for many tourists are Costa Rica, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thainlandia, Turkey, and United States of America. 8 In this paper, our intention is to consider the tourist as a person with an emphasis on the human and the emotional aspect. Not included in the health consumer commodification process, but as a person who seeks a better state of health. 9 Forum on the Internationalization of the Italian Health 2016, Rome; Report Observatory Private Consumption in Health (OCPS), SDA Bocconi, Milan.
There are more than 200,000 Italians who are traveling because of sanitary issues. At least, a quarter of this, 200,000 Italians ask for medical care dentistry. Most treatments in specialized health tourism dental are in Eastern European countries, Croatia, Hungary, and Romania (with Albania that's growing up). For the Italians, it is easy to get there in these countries, especially if they live near the airport. It is quite clear that these are countries where the cost of dental care is much lower than in Italy. Often the dentists (in these countries) have even studied abroad. The promotion of health treatment is very aggressive and aims almost exclusively on the Web support; in addition, all medical treatments are combined, with the basic tourist services like accommodation, food, shuttle service, etc. and excursions in the area who takes care to these tourists who speak Italian.
Precisely of this type of health tourism, we will deal in the next section.

Low-cost medical tourism of Italians
In this section, we will deal with the case of the health travels of Italians to foreign destinations where there are specialized institutions in dental care.
Thousands of Italians are contacting low-cost dental clinics in countries belonging mainly to Eastern Europe, and as we have mentioned before, it is a growing phenomenon.
Countries such as Croatia, Bulgaria, Romania, Slovenia, Poland, and Albania are in the last years the European leaders in dental health tourism market.
In recent years, we are seeing a proliferation of so-called low-cost dental centers, or commercial chains, mostly franchised, offer dental services at low prices.
Several clinics offer "all inclusive packages" at very low prices. In the "all inclusive," beyond the costs directly attributable to the dental expenses in the strict sense, in many cases, the costs of travel, the stay in the place where the clinic and excursions in the area is located are included.
The very low cost relative to the "all inclusive package," is due, according to what these clinics confirm, to the fact that "everything costs less" than the other countries of Western Europe: the rental of commercial premises, the average salary of a dentist, the cost of electricity, water, heating, expenses for advertising, administrative costs, taxes [14]. Indeed, the Italian president of the National Council of dentists, Dr. Giuseppe Renzo, in a 2015 interview said that "Italians look for alternative health services to cope with the crisis period" and because of the high prices of dental care in Italy according to Istat "over 8 million citizens would prefer not to heal mouth and teeth." In fact, in an article in the Italian newspaper "Il fatto quotidiano" in talking about low-cost dental tourism is reported an interview with an Apulian lady who alleged that she was aware of the possible risks to go to Albania to dental care, but the Italian prices would not have permitted to care of her teeth; moreover, it would have taken little time to arrive in Albania, and that she was very satisfied with the reception saying "they treat me like a queen, they cuddle me, they offer me the stay and make me visit the castles" [15]. Furthermore, Dr. Renzo stated that "dentistry in Italy is based in large part on a private network of professional firms whose basic costs are on average four times higher than those faced by professionals from other countries. The tax is 22% compared to 4; VAT cannot be deducted; the costs for collaborators are a weight on the cost, but their presence is essential to ensure safety and hygiene" [16]. On the other hand, the Italian dentists assign to the low cost of dental services low quality [17], mainly with respect to sanitary regulations, the respect of clinicians time, and the necessity of subsequent checks [18].
The dental tourism in recent years has made its history to Albania. There are several clinics on the Albanian territory, as many are also, the individual dental practices. Among the different realities encountered in our research, we wanted to analyze the case of "Dentists in Albania-Viaggiare e sorridere" [19].
In their Web page, they immediately show the fact that in Albania many of them speak, even correctly, the Italian (75% of the population) putting the possible Italian customer at ease and reassuring him, as well, also, they reassure on professionalism and quality of materials used (that they define high), they perform the relevant certifications and that they offer 5 years Warranty [20].
Albanian dentists reassure the potential customers on the qualitative aspect of their services, explain why their prices are so low compared to Italian dentists, attributing the reason to lower taxes, saying that in Albania tax pressure affects 10% while in Italy 55%, and the lower labor costs are due to a lower cost of living. In their opinion, it would lead to savings for the Italian patient tourists by 60% compared to what they could spend in Italy.
Another element that it should entice potential Italian customers to turn to them is the so-called word of mouth. In fact, on the website, dozens of testimonials were published that highlight the quality of services offered, the main motivation of the trip, that is, the economic issue and the tourist aspect. A witness, in fact, declares: "I hope nobody feels offended, I want just to tell my experience: in Italy, our doctors charge 4 times the cost of performances more than the Albanians, often abusing of the good faith of our patients and of our lack of information with the result of a medical service of the third world! This is what happened to me in Italy. That's why I want everyone to know about my experience with Viaggiare e sorridere. In Albania, for three certified dental implants made in Europe and the extraction of teeth 3, I spent EUR 1,400.00, and I was operated by a skilled doctor, who teaches Dental Implantology at the University of Tirana and by her husband too. The intervention lasted only 55 minutes as opposed to Italy, in fact the Italian dentists to justify the excessive price make you go several times ending up losing even 3 months. I saw people from all social backgrounds enter in this clinic equipped with the best three-dimensional machinery and hygiene at par with the best clinics in the world, I saw people, which they hugged each to other and then they decided to exchange they phone numbers, people pleased to have found a smile without signing a mortgage. A unique professionalism, many money saved and the stay is free, as also the taxi for and by Tirana to airport on arrival and departure and outings to discover the beauty of their land with the company of reception staff who speak Italian. A real holiday of well-being, which is why I thank and advise everyone the clinic Viaggiare e sorridere" [21]. Among other things, each patient/tourist who has left his testimony has left their contact information in case any potential customer wants to know more.
In Albania, low prices are not the only element to attract customers' attention, there are other elements as: a detailed range of interventions and services offered, the curriculum of some dentists and professionals who are part of the medical staff and not, the reviews (all positive) of their patients/tourists; "Dentists in Albania" also uses the "card" of the holiday, offering, among other things, a free stay for two people, and both the transfer to the hotel and the reception service: at the airport, there will be an attendant who will speak properly in Italian and that he will welcome them, he will be available to patients-tourists from 9 AM to 21 PM to resolve any problems on the stay or even to play the role of tour guide of the city. In addition, the reception agent will be available 24-24h contacting him by telephone.
Even before the trip, they offer their availability to clients in the organization of the trip, advising how to reach Tirana "stress-free and save a lot of money." The tourist aspect is repeatedly quoted on the website where, among other things, you can read "beyond to low-cost professional dental care, you will have the opportunity to take a holiday in a wonderful city like Tirana, all without spending just a euro for the stay and benefiting of all the services that you want." It is some years now, that some of these dental clinics have opened offices in Italy where they exclusively, do free visits with the purpose of provide quotes. Among them, there is the case "Dentists Croatia low-cost," which opened an office in Verona for "a free estimate, to explain the treatments, prices, to answer all your questions freely, and to give you all the information related to your stay in Croatia." For free, no-obligation appointments call us at our number "…Cell…Email…" [22]. Also in this case, the bus trip, starting from some cities reported on the website, is free. It is to be noted that accommodation is free sometimes subjected to the cost of the performance that a patient goes to support it and, in any case, the patient's accommodation does not happen in a hotel but in an apartment. In particular, the dental office specifies: "During your dental care, we offer a FREE comfortable apartment in the center of RIJEKA/RIVER Croatia near the sea with five beds. The apartment is free if you spend at least € 1000/1500 in dental care" [23].
Actually, in this case, by some researches carried out on the Web, it is not a dental clinic, but it concerns a real travel agency that manages the health travels. Indeed, by analyzing other websites offering low-cost dental care in Croatia, we realized that another website had the same addresses of "Dentists Croatia low-cost," and it is the following website www.viaggideldente.info [24]. The latter, it is known as the "Tour operator of dental savings," offering free travels by bus from some cities in northern Italy, low-cost dental care "in the best dental practice in Croatia" [25] and the opportunity to book your stay at favorable prices in the apartment.
However, the proliferation of dental clinics and dental low-cost studies in recent years has become an increasingly important phenomenon, and, therefore, the online offering of lowcost dental tourism is really impressive. Even in Italy dental centers specialized low cost are springing to try to attract these patients/tourists who want to be cured at a lower price.
Although, now, as we have seen, competition in the European scenario, in terms of cost and quality, it really is ever more.

Conclusion
In our discussion of the issue, we refer to the patient/tourist in terms of an exaltation of humanity. We refer to the person and his emotional sphere, which led him to travel to search for a better state of health [26]. Rests in the economic and marketing logic and activates processes for which he becomes a consumer, but he remains a person driven by doubts, fragility, and hope to the pursuit of happiness.
The medical treatment related to dental care is among the categories of health (medical) tourism, which refers to disease conditions and to ones of the esthetic improvement.
The research shows that the main reasons why Italians do dental care abroad are due to saving time and money. As well as because distance, communication, and knowledge of the language are not a real problem. Finally, using in a wise way the Web, there is no needs either of large economic investments to create promotion nor advertisements [27].
Italy is not among the top destinations for foreign health tourism, even if relying on a health care system, it is between the most efficient in the world. Italy was always been one of the most important tourist destinations in the world. Because of this, it is possible to arrange strategies that allow Italy to grow up the market related to the health tourism.