Carmen Valache in Istanbul -
Pristine facilities, high-tech equipment, renowned experts, luxurious spas, friendly and clean-cut nurses and doctors, services reminiscent of five-star hotels, all-inclusive packages in exotic destinations: medical tourism is big business these days.
And now Turkey is becoming a big player in this $50bn a year business, rising in the ranks of the top-ten medical destinations in the world after attracting over 400,000 medical travellers last year. The sector has certainly been on the radar of domestic and international investors, having drawn in big names like Khazanah Nasional, Malaysia's sovereign wealth fund, and the Emirati Abraaj Group in recent years.
Perhaps nothing symbolises Turkey's emergence in the market of glitzy healthcare facilities than the Bilkent Integrated Healthcare Campus – a $1.3bn project that is being constructed by an Azerbaijani company with German money, which will cover 1.2mn square metres outside Ankara, employ 8,000 staff, and treat 35,000 patients a day once completed in 2018. Touted as "Turkey's largest ever project under the republic", the complex will also include a hotel resort and a conference area, as hospitals do.
But behind all the money that is pouring in and the picture-perfect image that Turkey’s medical travel industry puts out, there are doubts about some of the statistics, parts of the sector are hurting, and the current violence and instability will do nothing to help business.
Travel for health
Medical tourism is certainly a budding, lucrative, and very location-sensitive business. Its size is estimated at $38.5bn-55bn by Patients Beyond Borders, with 11mn cross-border patients travelling every year for medical procedures, spending between $3,500 and $5,000 per visit. Americans and Western Europeans account for the lion's share of medical tourists, with an estimated 1.2mn Americans crossing the border with Mexico every year in pursuit of better teeth, lap-bands, plastic surgery and a number of other elective procedures. Chronically ill patients will rarely travel for medical purposes, because they require constant follow-up.
However, even in the most popular healthcare travel destinations, like Thailand and Singapore, which report over 1mn medical tourists a year, foreigners account for less than 10% of total patients; of those, over 90% come from neighbouring countries. So while the trend is growing, its proportion in the overall healthcare business remains relatively low, and the mobility of patients limited.
The uncontested front-runners in the world of (glitzy) medical facilities are Thailand and Singapore, which boast names like Thailand's Bumrungrad International Hospital or Singapore's Gleneagles Hospital, which are legends in the world of medical tourism. As Singapore's prices have risen sharply over the last decade, other contenders in South and Southeast Asia have emerged, most notably Malaysia, India and Taiwan; the Philippines and Indonesia are also slowly making headway, catering mainly to Western European, Chinese and Australian patients.
On the other side of the Pacific, Mexico is the leader in medical tourism in the Americas thanks to its shared border with the US. Brazil, meanwhile, is a plastic surgery centre, but caters largely to the domestic population and, to a lesser degree, other South Americans.
Across the pond, Europe's ageing population and congested public healthcare systems have prompted many Western Europeans to seek a cheaper private care nearby, which has led to the rise of Emerging Europe, Turkey and Israel in the medical travel industry. Since the Arab Spring started in 2011, the number of Middle Eastern patients has also increased tremendously, and unsurprisingly they favour Turkey over Israel.
Russians, Central Asians, particularly Turkic peoples like Azerbaijanis and Turkmens, and patients from Southeast and Eastern Europe account for the rest of the foreign patients in Turkey. While the country's prices are not nearly as low as India or Thailand's, they are a good 50% lower for certain procedures, like heart bypasses, compared to prices in Germany. Its proximity to the abovementioned source markets also makes Turkey a destination of choice for medical tourism.
Reliable statistics are notoriously difficult to obtain in this business. In an effort to boost their standing in the industry, many countries will count every single foreigner that sets foot in their hospitals, including foreign residents who want flu vaccines or pissed-up tourists.
Meanwhile, institutions like the US-based Joint Commission International (JCI), a globally-recognised accreditation body, have profited from the growth in medical tourism: over 600 medical facilities in developing countries have sought their accreditation to date, and their number is rising at 15% to 20% a year. JCI is the healthcare version of Moody's rating agency; if you do not have their accreditation, fearful patients tend to avoid you.
Technology and reputation are equally as important as location in the world of medical tourism; Americans are unlikely to travel to Turkey for treatment, regardless of how good a treatment they might get, just as much as Germans are unlikely to travel to Mexico for the same reason.
Setting up a profitable business that caters to medical tourists requires a great deal of investment and patience, for not only do hospitals have to hire highly-qualified staff and purchase cutting-edge technology, but they also have to do significant preliminary consulting for potential patients, which only pays off if the latter chooses to undergo the procedures that they are interested in. Word of mouth from former patients and general practitioners from source countries is a great referral for such facilities, for which building up their reputation is another significant investment.
In rude health
In comes Turkey, a popular beach and cultural tourism destination on the edge of Europe that receives upwards of 40mn tourists every year. A relatively liberal Muslim-majority country, with a wealth of culture and history, it appeals to both Europeans and Middle Easterners. A service-oriented and fast developing high-tech economy, Turkey is famous for its hospitality, for its skilled workforce – and increasingly its affordable medical costs.
According to the Turkish Statistical Institute, the country has seen a surge in medical tourists from 109,000 in 2010 to over 400,000 in 2014, putting the country as the sixth most popular destination for medical procedures in the world. But Ankara doesn’t plan to stop here: it aims to become one of the top five medical destinations in the world, and to attract 700,000 medical tourists with a turnover of $8bn by 2017, and for 2mn tourists and $20bn in turnover by 2023. The country's goals are feasible, seeing how foreign patients spend a significant $2,000 to $4,000 per procedure, and between $9,000 and $12,000 for the entire visit.
The Turkish government is keen on overhauling the country's healthcare system, having embarked on an €10bn programme to expand and improve public health infrastructure. But medical tourism remains a private affair, for over 70% of the foreigners treated in Turkey choose one of the country's almost 1,000 private hospitals. Private operators are more than happy to cater to foreigners, who cover their costs out of pocket and are charged several times more than insured Turkish citizens for the same procedures.
But for all of Turkey's keenness on medical travel, the number of foreigners in its hospitals remains tiny compared to the approximately 18mn Turks who use public and private hospitals every year. Besides, the statistics the government puts out could be exaggerated. The largest operational private hospital group in Turkey at the moment, Acibadem Healthcare Group, reports that it accounted for 20% of the $750mn medical tourism turnover in the country last year, but only treated about 42,000 medical tourists during that time, which it claims represents 15% of the total medical tourists visiting Turkey. That would put the number of Turkey's medical tourists at around 280,000, under the government's estimates.
Acibadem Healthcare, which operates 17 hospitals in Turkey and one in Macedonia, treated over 3.5mn patients in 2014. A reflection of how important the Turkish market is to Acibadem, the group does not hire non-Turkish speaking doctors, but does hire Turkish-speaking Azerbaijani and Kazakh doctors that studied in Turkey, as well as Turkish doctors who have studied abroad, according to Gokhan Izlisu, Acibadem's international relations supervisor. "In addition to our hospitals, Acibadem operates several other business lines, which include testing laboratories, ambulance services, insurance, construction project management, catering, and even a medical school,” Izlisu tells bne Intellinews in an interview. "We attend patients from 42 different countries… and Western European countries only account for 1,500 to 2,000 of our 42,000 medical tourist patients.”
The rest of the patients come from the Balkans, the Middle East, and Russia/ Commonwealth of Independent States (CIS), according to Izlisu, which perhaps explain why neurosurgery, orthopedics, oncology and organ transplants are the most popular procedures among its patients, and not plastic surgery. "Plastic surgery and dentistry are the most popular with Western Europeans," he says.
Meanwhile, Middle Easterners are more concerned with their hair. "Most Arabs that approach us do so for hair implants," Dr Dilek Uzer from intermediary medical tour operator Turkey Health Tour, tells bne Intellinews. As for the number of potential patients approaching the tour operator, Dr Uzer claims that it depends on the amount of online marketing the company does. "Western European patients are particularly sensitive to technology, so their number increases when I invest in online marketing; they are very well-informed when they come here," she confesses, adding that on a good month her company could secure 40 package deals from medical tourists, and that even without any promotion she still attracts over 15 tourists a month.
As for competition from other tourism destinations like Singapore and India, Izlisu explains it does not worry them. "We are co-owned by Malaysia's sovereign wealth fund, Khazanah Nasional, and by Japan's Mitsui family, and we have partnerships with most of the renowned hospitals in Southeast Asia," he explains. "We are their partners in Europe, and cater to different geographies, therefore we are not competitors."
However, nearby locations like Israel and potentially India do pose some threat, particularly because Turkey's healthcare industry is highly regulated. "In Turkey, organ donors and recipients must be related; the same goes for sperm or egg donors for in-vitro fertilisation, and gender selection of foetuses is illegal. Meanwhile, in countries like India and Israel anyone can donate an organ," he confesses, but adds that Acibadem is just as concerned with ethics as the Turkish government.
Not all well with wellness
One part of the medical travelling business that Turkey is famous for, wellness tourism, is not doing so well, according to Carmen Siebel, a spa consultant with 25 years of experience advising hotel spas in Istanbul and in Turkey's beach resorts. “A decade ago, the focus was on high quality and inclusive packages, which is how Turkey attracted high-quality wellness clientele from Western Europe," she tells bne Intellinews.
But lately, she explains, hotels have moved to outsource their spas to outside companies, which have been forced to lower prices, and therefore the quality and diversity of treatments. “Thalassotherapy and expensive procedures like Botox injections used to be an important revenue source for us, but not anymore. Nowadays, we are operating with low-quality products and performing basic procedures like massages and facials," Siebel complains, adding that nepotism is a big problem in the spa business in Turkey. “Many of these hotels are family-owned, and they appoint inexperienced offspring in management positions, which is bad for business.”
Meanwhile, regular hotels seem to be benefiting from the rise in medical tourism in Turkey. When this reporter stayed at the four-star Gorrion Hotel in the vicinity of Istanbul's Ataturk International Airport in December 2014, the place was bustling with Middle Eastern medical travellers whose crutches and eye patches gave a distinctly clinical feel to the place. "Those are our patients," Izlisu admits. "One of our largest hospitals, Atakent, is located close to Ataturk airport."
Others like Celal, a doctor who works in the public healthcare system and who asked not to have his last name published, complain about the drain on human resources from the public to private hospitals that medical tourism is contributing to. "Private hospitals offer higher salaries, but most Turkish patients who use social security cannot afford the co-payments, so they will continue to go to public hospitals. Meanwhile, private hospitals are stealing good doctors away from public ones," he notes.
But with the help of Turkish Airlines, the airline that claims to operate flights to the largest number of destinations in the world, medical tourism is bound to flourish. In October, Turkish Airlines announced it would offer 50% discounts to medical tourists who seek treatment in Turkey and can provide proof from the medical facility where they were treated.
For all Turkey's shortcomings – and the recent upsurge in violence as the poltical situation worsens is one more – its many benefits such as a location close to Europe and the Middle East, and educated and skilled workforce will continue to support the growth of its medical healthcare.
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