HEALTH TOURISM AND "SMART SPECIALISATION"

Abstract

The Europe 2020 strategy mapped out the direction for the achievement of smart, sustainable and inclusive growth and development. The purpose of the paper is confirmation of the hypothesis that health tourism, in all its complexity, interdiciplinarity and systematic approach to problems, is an ideal model of "smart specialisation", not only of tourist regions, but the entire destination at the national level. National competitiveness in this paper can be improved by increasing innovation capacity by focusing on health tourism and health resources in general, through which also on the delivery of the objectives of the Europe 2020 strategy. The main research results are related to the fact that there is still no single definition of health tourism in theory and practice; however, using numerous serious research, the paper provides a general insight that health tourism can be viewed through the elements of the tourist offer which reflect the adequate combination of wellness and spa services with medical tourism services. The main conclusions in the paper are associated with some of the flagship initiatives in the document "Europe 2020 - A European Strategy for Smart, Sustainable and Inclusive Growth" regarding health tourism, which, due to high correlation with smart, sustainable and inclusive development, proves to be a real developmental challenge and choice for reaching national and regional competitiveness.

Headnote

Abstract

The Europe 2020 strategy mapped out the direction for the achievement of smart, sustainable and inclusive growth and development. The purpose of the paper is confirmation of the hypothesis that health tourism, in all its complexity, interdiciplinarity and systematic approach to problems, is an ideal model of "smart specialisation", not only of tourist regions, but the entire destination at the national level. National competitiveness in this paper can be improved by increasing innovation capacity by focusing on health tourism and health resources in general, through which also on the delivery of the objectives of the Europe 2020 strategy. The main research results are related to the fact that there is still no single definition of health tourism in theory and practice; however, using numerous serious research, the paper provides a general insight that health tourism can be viewed through the elements of the tourist offer which reflect the adequate combination of wellness and spa services with medical tourism services. The main conclusions in the paper are associated with some of the flagship initiatives in the document "Europe 2020 - A European Strategy for Smart, Sustainable and Inclusive Growth" regarding health tourism, which, due to high correlation with smart, sustainable and inclusive development, proves to be a real developmental challenge and choice for reaching national and regional competitiveness.

Keywords: wellness, spa, medical tourism, knowledge triangle, competitiveness, innovation.

Jel Classification: I150; O310

INTRODUCTION

The direction that will lead to the achievement of smart, sustainable and inclusive growth and development is mapped out in the Europe 2020 strategy. The purpose of this paper is to confirm the hypothesis that health tourism, in all its complexity, interdiciplinarity and systematic approach to problems, is an ideal model of "smart specialisation", not only of tourist regions, but the entire destination at the national level. National competitiveness in this paper can be improved by increasing innovation capacity by focusing on health tourism and health resources in general, through which also on the delivery of the objectives of the Europe 2020 strategy

The main research results refer to the fact that the paper provides a general insight that health tourism can be viewed through the elements of the tourist offer that reflect the adequate combination of wellness and spa services with medical tourism services.

In addition to this introduction and conclusion, the paper is divided into three chapters. The first chapter covers the basic literature, conceptual definitions and hypothesis of the paper. It substantially includes theoretical foundations of health tourism and "smart specialisation", methodology, and the set hypothesis. The second chapter briefly explains the scientific methodology used, and the third chapter delivers the results of the discussions related to the relationship between health tourism and "smart specialisation" through the analysis of the relationship between flagship initiatives supported by the EU growth strategy Europe 2020.

1. BASIC LITERATURE, CONCEPTUAL DEFINITIONS AND HYPOTHESIS OF THE PAPER

Presently, orientation on health tourism is evident in almost all touristically developed countries and regions, which is covered by eminent international (Clift and Page 1996; Wang and al. 2000; Pilzer 2002, 2007; Horx 2001; Conell 2006, 2013; Smith and Puczkó 2009; Hall 2011) and national experts (Alfier 1994; Andrijsevic and Bartoluci 2004; Hitrec 1998; Kusen 2006; Pancic-Kombol 2000; Rozanic 2000; Vukonic 2010 and others). According to them, the entire tourism phenomenon, in accordance with its functions in physical and psychological recuperation of the body, can be categorised, in a broader sense, in some of the shapes and forms of health tourism. In this context and in everyday tourist practice, health tourism as a selective form of tourism is expanding; it is located in a wide range of services, from recreational aspects of wellness tourism to hospital tourism organised by catering firms i.e. health facilities providing health tourism services.

There are various definitions that are most commonly used in domestic and foreign literature, and it is useful to list some of them here. Firstly, we will keep within limits of definitions in the field of medical tourism, followed by wellness tourism and spa industry and, finally, health tourism.

Comprehensive analytical studies of medical and wellness tourism appear in the books "Health and Wellness Tourism" (Smith and Puczkó 2009), and in "Handbook on Medical Tourism and Patient Mobility" (Lunt, Horsfall and Hanefeld 2015), in which the authors set the definition of medical tourism highlighting two types of medical treatments undergone by tourists: surgical treatment (e.g. surgeries), or therapeutic treatments (e.g. participation in a medical treatment). Medical tourism can be defined as a trip to nearby destinations to undergo medical treatments (Hopkins et al. 2010) such as surgeries or other specialist interventions. Medical tourism [...] can have two main forms: surgical and therapeutic. There is a clear difference between them. Surgical treatment surely includes specific actions, while therapy is an element in the treatment process" (Smith and Puczko 2014). In general, medical tourism can be categorised into three groups, depending on where the tourists go to get medical services (Medical Tourism - Guide 2015)

Medical tourism is often primarily associated with "outbound" trips, i.e. the possibility to obtain specific medical services faster and much cheaper than in one's own country (low-cost destinations, poor countries).

The history of wellness dates back to ancient history and refers to: Ayurvedic Medicine (India, 3000 BC); Chinese Medicine (Emperor Sheng Nung, 2038 -2698 BC); Thai Traditional Medicine; Japanese Onsen; Russian Steam Bath; Tell el Amarna Therms (Egypt, 1350 BC); Greek Thalassa (Hippocrates, 460 -355 BC); Roman Thermae/Balnea Publica (II BC-III AC); Arabian Medicine (8th-15th century, Al Razi 850-923); Turkish Haman; Dead Sea Salts Baths; Egyptian Mansuri Hospital (Cairo, 1248) - Travellers came from all over the world; Native American Sweat Lodge; Mexican Temazcalli; Australian Aboriginal Steam Baths; Mineral Springs in Spa near Liége (14th); Climatotherapy (18Ith/19th centuries) in Madeira and Canary Islands; Scientific Medicine (19th century). Recent years: 1959 - Inauguration of Golden Door Spa in California; 1987 - Official Beginning of the Global SPA Industry - SpaFinder Magazine; 1991 - International SPA Association - ISPA (USA); 1996 - European SPA Association.

This historical medical heritage had a decisive influence on modern definitions of wellness that are usually focused on holistic or integrated approach to health, from disease prevention, self-responsibility for health and one's own well-being, to the idea of achieving physical (body), mental (mind), and spiritual (spirit) body harmony, resulting in optimal health balance (WHO 2015, 47). Responding to the current emphasis on health and wellness in modern society, this industry has been growing rapidly in the past two decades (Choi 2015).

One of the first authors who wrote specifically about wellness as an industry, rather than just a concept, is an economist and entrepreneur Paul Zane Pilzer (2002). In his opinion, the wellness industry is proactive. It offers products and services for healthy people in order for them to feel even healthier, to look better, to slow down the aging effects and/or prevent disease development. People voluntarily become customers of the wellness industry. Conventional medicine is reactive. It provides products and services for people with pre-existing disease, in terms of symptoms or elimination of the existing disease. People become users of these services because they are ill, and this is not voluntary, but a necessity (Pilzer 2007).

Travis and Ryan (2004) point out that "Wellness is a process... that expands the definition of health and includes the integration process characterised by awareness, education and growth" (Travis and Ryan 2004, quoted in Global Spa Summit 2010, 75).

· Wellness is a selection of decisions aimed at optimal health.

· Wellness is a way of life and a lifestyle designed to achieve the highest potential for one's own benefit.

· Wellness is a process that develops awareness of non-existence of the end point in this process; health and happiness are possible at any moment, here and now.

· Wellness is balanced energy channeling - energy that you get from the environment, that is transformed inside you and returns to the environment, thus affecting the world around you.

· Wellness is the integration of body, mind and spirit - growing value of oneself in order to think about and feel everything that has an impact on one's health condition and overall health in the world.

· Wellness is self-love.

National Wellness Institute (NWI) uses the following definition of wellness developed by the founder of the Institute Bill Hettler in the late 1970s: "Wellness is an active process in which people consciously make decisions for more successful existence" (National Wellness Institute, quoted in Global Spa Summit 2010, 73).

In Europe, the word wellness is mainly borrowed from the USA. However, in their cultural tradition, Europeans more often use the terms spa, baths, health resorts for preventive and curative purposes, and wellness is thus more directly connected with activities, including sanatoriums, health resorts, thalassotherapy and various types of non-medical treatments offered in such facilities (Miller 2005).

In comparison with the USA, wellness in Europe also tends to be more closely connected with cosmetic, healing, and physical activities than with alternative medicine and health care (Tourism Review 2010). A common point of many definitions of wellness (Spas and the Global Wellness Market 2010, 7) is that wellness is:

· Multidimensional - which means that most of the leading definitons of wellness include a model that represents from 2 to 14 or more dimensions, often including physical, mental, spiritual, and social dimension.

· Holistic - wellness is a broader concept than physical health or fitness, with emphasis on the well-being of the whole person. It is not just the absence of physical illness, but an approach that emphasises all aspects of a person - body, mind and spirit - functioning in harmony.

· Changeable over time - Wellness is not a static state or end point; it is quite often presented in continuity and represents the optimal level of wellness that an individual tries to achieve and increase throughout the lifecycle.

· Individual, but also influenced by the environment - wellness is a process that is carried out at the individual level; it is included in the behaviour and practice of healthy individuals promoting personal well-being. However, personal wellness is also influenced by the living environment.

· Self-responsible - severly ill people usually rely on medical treatments to solve their problem and restore health. Most advocates of wellness philosophy point out the responsibility of each individual to take responsibility for their own health and to engage in such behaviour and activities that will proactively prevent diseases and promote a higher level of health and well-being.

The concept of health tourism should be considered in terms of basic elements that make up its structure - health and tourism. The World Health Organisation (WHO), as an umbrella institution, defines health (WHO 2006, 1). In parallel, the UN World Tourism Organisation considers tourism as "totality of activities of persons travelling outside their usual environment for leisure, business or other purposes" (UNWTO 2012); therefore, health tourism in this context should be considered through the synergy of their interaction. In his work Health and Medical Tourism (2011), C. Michael Hall covers most thoroughly the field of health, wellness, medical and spa tourism and provides an overview of relevant and comprehensive literature. He refers to numerous papers on medical and health tourism recorded in the Scopus database for the long period between 1963 and 2011.

The Global SPA Summit (2010) attempts to define health tourism in its entirety in terms of basic division of conventional medicine intended for the ill, the so-called reactive approach and the so-called CAM, or Complementary and Alternative Medicine, directed to methods of life improvement or the so-called proactive approach to health. This, in fact, shows the insufficiently defined approach to the problem of health tourism, because at the same time, the so-called wellness paradigm includes both reactive and proactive approach to health. Within this image and a single paradigm, left side is separated from the right, i.e. medical tourism from wellness. Complementary and Alternative Medicine (CAM) includes diferrent types of health care through holistic, mental and spiritual systems, practice and products which are generally not considered part of conventional medicine. The dominant health care system includes e.g. homeopathy, chiropractic, traditional Chinese medicine, ayurveda, energy healing, meditation, herbal remedies, etc.). CAM is also used for treatment (reactive) and wellness improvement (proactive), so that it covers both sides of the so-called wellness continuum.

In his work Health and Medical Tourism (2011), C. Michael Hall covers most thoroughly the field of health, wellness, medical, and spa tourism and provides an overview of relevant and comprehensive literature. He refers to numerous papers on medical and health tourism recorded in the Scopus database for the long period between 1963 and 2011.

Hall covers in detail how some authors define health tourism, e.g.: Goeldner (1989, 7) defines health tourism as (1) staying away from home, (2) health [as] the most important motive, and (3) carried out freely in the environment. Goodrich and Goodrich (1987, 217) and Goodrich (1993; 1994) define health tourism in terms of a narrower concept as an "attempt to attract tourists by tourist accommodation facilities (e.g. hotels) or destinations (tourist destinations) with the promotion of their health services and facilities".

The terms "health tourism" and "medical tourism" are usually equated in literat ure, or discussed as two different concepts. The terms "wellness", "wellbeing", "SPA" "health tourism", "holistic tourism", etc. are sometimes viewed as subsystems of health tourism, and sometimes as its extension, or even a wider framework (higher-order term), into which health tourism more or less fits. Perceptions vary significantly in different parts of the world. This is the reason this issue needs to be clearly defined and based on the research results of leading authorities and take into account the examples of best international practice.

Research on the use of words and associations to those words in the respondents' definitions are highly indicative; they show that: medical tourism is mostly associated with the words procedures, surgeries, health, care, treatment. Wellness is mostly associated with the words health, spa, services, destination, relaxation, treatments, medical, and programmes. The words medical and wellness are equally dominant in the association with health tourism, which indicates that respondents generally associate health tourism with both conditions (Global SPA Summit 2011, 88).

Health tourism is a complex tourist product which includes many specialised contents and services on trips motivated by the need to improve health and quality of life. Tourism Development Strategy of the Republic of Croatia until 2020 (2013) and the National Health Care Strategy 2012-2020 (2012) identify three types of health tourism: wellness, health and medical tourism (Figure 1).

Interrelationship between individual forms of health tourism and service providers can be schematically illustrated as follows, which is also closest to the single definition:

This overview provides a general insight that health tourism can be viewed through elements of the tourist offer that reflect adequate combination of wellness and spa services with medical tourism services. It is important to note that no wellness services are ever realised in clinics and hospitals as medical facilities, while medical tourism with its services takes place only in specialist hospitals (where wellness services are also provided with health tourism) as well as in hospitals and clinics providing only medical services.

Smart specialisation is a strategic concept formed by a group of EU experts aiming to reduce the competitiveness gap between the European Union and the United States of America, which stems from a lower level of economic and technological specialisation of European countries, particularly at the regional level. The Lisbon Strategy for Growth and Jobs is a joint response of the European Union to the challenges of globalisation, demographic changes and knowledge society (Kandzija and Cvecic 2010). In order to overcome the crisis and prepare Europe for the next decade, the European Commission launched the Europe 2020 strategy adopted by the European Council in 2010. This Strategy identifies three key drivers of growth which will be implemented in concrete actions at European and national levels. Approach to development based on innovation, education and research has developed in the past few years. This approach is called the knowledge triangle. Education, research and innovation are the three sides of the knowledge triangle between which there is cooperation of educational institutions, research organisations and the business sector (Casey 2013; Horvat 2012). The direction which should achieve smart, sustainable and inclusive growth is mapped out (Dragicevic and Obadic 2013). In order to achieve this goal, it is necessary to work on the development of education, research, innovation and entrepreneurial culture. According to Dragicevic and Obadic (2013), competitiveness is a dynamic concept that is constantly changing, adapting and improving. It is created in micro- and meso-economic structures in companies and clusters, which also affects macro-economic growth and development (Porter 2001). Clusters are a very fertile ground for innovation, because they are constituted in accordance with the modern innovation process and, as such, affect the competitiveness (Dragicevic and Obadic 2013; Horvat and Kovacevic 2004; Tijanic 2009). "Smart specialisation" is primarily based on the knowledge triangle (Horvat 2012), i.e. on innovation.

It should be noted that very few doctoral and master's theses in Croatia cover and analyse the phenomenon of sustainable, smart and inclusive development defined by the Europe 2020 strategy and the so-called "smart specialisation". Sustainable development is covered from the aspect of education (Lay 1998), in terms of sustainability indicators (Simlesa 2008), environmental protection (Korosec 2012), and the concept of "smart specialisation" (Varicak 2014).

Knowledge and innovation are the foundation of economic growth and development as well as job creation. This approach is now important, not only for high technology sectors, but for all sectors of the economy, and it has a special place in tourism as an important segment of final consumption in which health industry and health tourism have an important place.

The paper is based on the following hypothesis: "Health tourism, in all its complexity, interdiciplinarity and systematic approach to problems, is an ideal model of "smart specialisation".

2. RESEARCH METHODOLOGY

In the scientific research and presentation of the results, many scientific methods have been used, of which the most important are the following: the hystorical method of collection of secondary data sources is used to analyse relevant bibliographic material and explain the used terms and definitions. Since there is still no single definition of health tourism in theory and practice, through the application of a number of serious research, using methods of analysis, synthesis, induction, deduction, and descriptive method, the paper provides a general insight that health tourism can be viewed through the elements of the tourist offer that reflect an adequate combination of wellness and spa services with medical tourism services. A comparative analysis has shown that national competitiveness in this paper can be improved by increasing innovation capacity by focusing on health tourism and health resources in general, through which on the delivery of the objectives of the Europe 2020 strategy. The method of abstraction and concretisation is used to prove the correlation between some of the flagship initiatives from the document "Europe 2020 - European Strategy for Smart, Sustainable and Inclusive Growth" and health tourism, which, due to its high correlation with smart, sustainable and inclusive development, proves to be a real developmental challenge and choice for reaching national and regional competitiveness.

3. "SMART SPECIJALISATION" AND HEALTH TOURISM

"Smart specialisation" implies the identification of unique characteristics and potentials of each country and region with emphasis on competitive advantages and gathering of regional stakeholders and resources around the vision of future based on excellence (Morgan 2015; Varicak 2014, 4). The European Commission has presented seven flagship initiatives that will enable progress under each priority (Europe 2020, 2014). We will only mention the following two initiatives that can be logically linked with health tourism:

· Priority theme "Innovation Union" aims to improve the framework conditions and availability of funding for research and innovation to ensure the ability to transform innovative ideas into products and services that create growth and jobs.

· Priority theme "An Agenda for New Skills and Jobs" aims to modernise the labour market and empower people by developing their skills throughout their lifecycle with a view to increase labour participation and better match labour supply and demand, including through labour mobility.

3.1. Flagship Initiatives of Smart, Sustainable and Inclusive Growth and Health Tourism

Flagship initiatives of smart, sustainable and inclusive growth and health tourism are based on:

Smart growth - health tourism based on knowledge and innovation. The main initiative of smart growth is the "Innovation Union" (Europe 2020 2010, 14). The objective of the initiative is to direct the focus of the research and development policy and innovation on challenges the society is facing. Health tourism is again very applicable in this segment, because innovation in health tourism make the necessary connection between new knowledge and application of this knowledge through innovation in the field of health and tourism. Demand for health tourism services in Europe is focused on several specialisations. Although data on the significance of certain specialist services vary depending on the source, there is no doubt that cosmetic sugery and dentistry are the most wanted medical services, and body treatments and fitness are the most popular segments of wellness. Wellness demand is motivated by the system of values in which health care, maintaining physical and mental abilities, learning about improvement and, even, lifestyle changes, are very important (Action Plan for Health Tourism Development 2014, 18).

Sustainable growth - promotion of health tourism as a competitive economy that makes efficient use of resources. Flagship initiative: "Industrial Policy for Globalisation Era" (Europe 2020 2010, 20) in the framework of the flagship initiative "Resource - Efficient Europe" (Europe 2020 2010, 20) advocates promotion of technologies and production methods that reduce utilisation of resources and increase investments in the existing natural resources of the European Union, where health tourism without a doubt also falls under this flagship initiative. Flagship initiative "An Industrial Policy for the Globalisation Era" stands for "increased competitiveness of the Europe an tourism sector" (Europe 2020 2010, 20) and within the same flagship initaitive, there is also "close cooperation with stakeholders from different sectors (business, trade unions, academics, NGOs, consumer organisations), to identify bottlenecks and develop a shared analysis on how to maintain a strong industrial base and knowledge and put the EU in a position to lead global sustainable development (Europe 2020 2010, 21). In the framework of this flagship initiative, health tourism is especially addressed in terms of increasing competitiveness of the European tourism market as well as cooperation of different sectors.

Inclusive growth - health tourism provides employment, which ensures economic, social and territorial cohesion (Europe 2020 2010, 21). Health tourism is the best guarantee that the benefits of economic growth will spread to all parts of the Union, including its outermost regions such as Croatia, thus strengthening territorial cohesion. In the framework of smart, sustainable and inclusive growth, health tourism is also covered in the flagship initaitive: "An Agenda for New Skills and Jobs" (Europe 2020 2010, 22). Health tourism is a strong impetus to the strategic framework for cooperation in education and training, especially life-long learning.

CONCLUSION

The Europe 2020 strategy mapped out the direction aiming to achieve smart, sustainable and inclusive growth and development. The purpose of the paper is to confirm the hypothesis that health tourism, in all its complexity, interdisciplinarity and systematic approach to problems, is an ideal model of "smart specialisation", not only of tourist regions, but the entire destination at the national level. National competitiveness in this paper can be improved by increasing innovation capacity by focusing on health tourism and health resources in general, through which on the delivery of the objectives of the Europe 2020 strategy.

The main research results refer to the fact that, in theory and practice, there is still no single definition of health tourism, but using a number of serious research, the paper provides a general insight that health tourism can be viewed through the elements of the tourist offer that reflect the adequate combination of wellness and spa services with medical tourism services.

The main conclusions of the paper are associated with some of the flagship initiatives from the document "Europe 2020 - A European Strategy for Smart, Sustainable and Inclusive Growth" in relation to health tourism which, due to high correlation with smart, sustainable and inclusive development, proves to be a real developmental challenge and choice for reaching national and regional competitiveness.

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