Dental tourism in Hungary

In dental tourism, the cost of treatment in the country of departure and the total budget (travel, accommodation, catering, further travel expenses) in the host country have the most important role to make the decision. In general, people can save 40-70 % of their money, depending on the nature and the location of the treatment. However, it is also a fact that under a certain threshold, below the savings amount, it is not «worth it» for the patient to travel. The geographic distance of the healthcare provider plays an important role in different types of treatment. For «minor interventions», such as dental care, it is not worth for health tourists to travel to other continents; Western European dental tourists typically travel to Eastern Europe. In case of larger, life-threatening surgeries, the necessity of intercontinental treatment is questionable firstly due to the long flight and, secondly, to the continuous post-treatment and possible complications. In scientific literature it is difficult to find accurate statistics about the relationship between the nature of treatments and the geographical distance of the sending/receiving country. Another aspect of decision-making is whether a relative or friend of the health tourist can accompany them to the treatment, and if it is possible, how big the total will be including the costs of the accompanying person. Generally speaking, the patients arrive with an escort to the destination country who can provide spiritual support and also nurse them.

Introduction

According to the extent and structure of demand and supply European countries can be divided into 4 groups. Germany, Austria, and Switzerland have been significant destinations and source countries of health tourism for a long time. Germany utilizing its wide selection of thermal baths has specialized in spa tourism, while in Austria and Switzerland the so-called mountain wellness, anti-aging treatments, and clinical health tourism are considered significant. According to data by Euromonitor International (2015) the increase of this sector's share is 11,1 % in Austria, while the same rate is 2,8 % in Germany. Wealthy, affluent and quality-oriented guests from United Arab Emirates, Russia, Romania, Switzerland and Kazakhstan often visit Austria for health care purposes and it is estimated that 10 % of the clientele of Austria's private clinics is made up by foreign patients. The reasons for such self-financed visits are primarily preventive medicine, the reevaluation of diagnoses received at home, post-operative rehabilitation and the treatment of cancerous tumours. While Austrian health care is considered excellent, the performance of its health sector is still behind that of Germany and Switzerland. Consequently, the country emphasizing wellness demonstrated by the «Austria the Well-being destination of Europe» motto, and lacking a relevant marketing strategy responding to current needs still has a tremendous unexploited potential in health tourism. Naturally, Austrians do not have to give up this type of product or option, as health and wellness tourism presents an alternative for those enjoying winter vacations. Winter resorts counteracted or offset the declining visitor numbers due to the lack or unreliability of snow wth the building of wellness hotels and other resorts. The most successful spa-providers combine the classic spa options with innovative health treatments, fitness programs, exclusive lifestyle programs, culinary offers, and other cultural or leisure time attractions. Germany's aging, yet affluent population represents a significant internal demand for traditional spas and clinical tourism, while less well-off Germans seek cure for their illnesses in Asian countries. Since the German health care system is considered the best not only in Europe but globally as well, German hospitals and clinics among them Heidelberg, Hamburg, and Stuttgart have been leading players in this sector. The high quality care, the highly trained doctors along with the short waiting lists attract wealthy patients from Eastern Europe, primarily, Romania, Bulgaria, and Russia, but also from the UK, North America, and the Arabian countries. The most often sought treatments are neuro and orthopedic surgery and cardiology. Furthermore, Switzerland's famed mountain resorts and therapeutic baths including Leukenbad in the Alps and the more than 2000 year old Baden are favored locations for post-operative rehabilitation. At the same time more and more upper middle class guests arriving from Saudi Arabia and Eastern Europe take advantage of the innovative servicescombinging traditional treatments with anti-aging and holistic programs. Swiss health tourism providers assign a high priority to healthy diets containing natural and organic ingredients provided by ecologyconscious farms meeting rigorous quality requirements. It is noteworthy to mention that due to the country's traditionally high esteem of the private sphere, a certain controversial and rather macabre type of health related tourism developed in Switzerland, namely euthanasia tourism. Besides Switzerland this practice is only allowed in the Benelux countries and said service is mostly used by clients from Germany and Great Britain.

Mediterranean countries (France, Italy, Spain, and Greece) have also recognized the advantages of health tourism and they aim to reduce the negative consequences of mass tourism by the development of wellness resorts and Thalasso therapy centres. While Great Britain and the countries of Northern Europe primarily participate in therapy-oriented medical or health tourism on the sender side, countries of Central and Eastern Europe take advantage of the available therapeutic and natural cure factors to present curative or medical tourism options [1]. Hungary is the leader in the dental and cosmetic surgery tourism market. Privately owned dental and cosmetic surgery clinics are significant and well-performing actors in the Hungarian health tourism sector. Yet, cardiovascular surgery, orthopedic surgery, opthalmology, onkology, gynecology, and urology present promising potential as well. Internationally acclaimed physicians, the cost effective application of innovative medical technology by famous surgeons (Hangody knee mosaic surgery method, Papp heart surgery approach) the continuous training, the increased size of the medical staff, the great Hungarian medical advances including the Bioptron lamp, Avemar, Вéгеś drops, Taxalbin, deuterium-free water along with the internationally famous medical training institutions (Peth0 Institute, medical universities) function as guarantees for the success of the Hungarian health tourism sector. As the private dental clinics in Budapest [2], and such towns at the country's western border as Sopron, Mosonmagyaróvár, and the vicinity of Gy0r are frequented by British, Irish, French, Scandinavian, and naturally, Austrian patients, Hungary is often referred to as the Mecca of dental care tourism. Dental tourism to Hungary makes up more than 40 % of the European market while its 21 % global share ranks it above Mexico (20 %) and India (15 %). According to a 2017 report of the Central Bureau of Statistics visitors from Slovakia and Austria representing 50 and 20 % of daily border crossing traffic respectively took advantage of the health, primarily dental care services in addition to VFR and shopping options. More than half of the aggregate day-based tourism receipts (87 billion HUF) were provided by Austrians, and one third came from Slovakian visitors. Dental care related expenditures are significant in both cases, with almost 50 % represented by Austrians.

1. Changing demands in health tourism, the emergence of new target groups

Market research focuses on the tourist or guest personifying demand and acting as a subject of thesys- tem. His or her needs, motivations and consumption habits provide the foundation for the development of a satisfactory supply.

While researchers tend to assign a crucial role to motivation, leisure time, and discretionary income in impacting demand, the concept of socialization [3], manifested in such impulses as treatment or prevention of disease, acquisition of medicine, or undergoing medical intervention along with seeking natural healing factors [4] should be focused upon as well. Unlike one's general health or susceptibility to diseases health consciousness or the willingness to participate in health-related travel is not genetically coded but results from a learning process. The role or significance of the family and later as a result of the broadening social context that of the school, peer groups and work place demonstrated among others by on the job health programs is undebatable. Last but not least as in consumer societies overall, prestige and the respective fashion trends can determine the demand for health-oriented travel as well [3].

The main features and motivations of the participants of health tourism have been only sporadically researched. Until now research programs focused on the typization of consumers based upon age and the utilization of the respective services [5]. While these factors play a definitive role, we must consider the significance of motivation since previously medical tourism was associated with older age groups and wellness with the younger generations. However, today, all age groups are represented in all product categories. Regardless of age group these customers spend a longer time at the locations where they receive the intended treatment, thus they demand comfortable, friendly atmosphere, personal touch, and special experience-based programs.

The increasingly health conscious middle aged and senior population includes relatively healthy, high spending custormers emphasizing the perservation of beauty, healthy diets, and age-specific exercise. Treating health as a value and striving for the long term maintenance of a high quality of life these people are willing to pay for the pleasant environment, the special relaxation experiences, and top quality services. They prefer resort spas providing all inclusive wellness and fitness services and thalasso therapy centres. The rising prevalence of anti-aging medicine, originating form the USA in the 1980s and appearing in Hungary in 2001 under the name of age-control provided by the Quintess Healthy Aging Club, is a recent development of Western medical science impacting the health tourism sector as well. The system oriented, preventive, evidence-based life-style medicine offers special opportunities for the preservation of physical and intellectual strength and sexual attraction guaranteeing high quality of life in the Third Ageor third stage of life both for the individual and society. Researchers revealed increasing interest towards these services among younger age groups as well. A survey launched in the spring of 2007 by the author of this essay questioned a sample of 284 university students. It can be concluded that 62 % of the respondents assign a high priority to prevention and want to lead a more health conscious life than their parents did

Those in need of rehabilitation primarily come from the middle or older age groups, but primarily seeking treatment for sports-related injuries, the younger population is represented as well. Guests requiring postoperative treatment prefer quite, tranquil surroundings not frequented by tourists and seek facilities offering wellness and spa options with special hospital, sanatorium or therapeutic hotel atmosphere.

Members of the health conscious Y generation, that is those in the early middle aged groups primarily arrive without children and desire regeneration. A large proportion of this clientele is made up by professional, highly qualified women, mostly singles. Such high paying guests seeking physical, psychological and mental, regeneration insist on facilities with a tranquil atmosphere while spiritual and creative programs enjoy growing popularity as well. Such customers favour medical-wellness facilities, holistic and yoga centres and represent a special type of health tourism, namely the selfness movement gaining popularity in Hungary as well. Visitors don't insist on thermal or therapeutic baths but prefer insititutions with special activity swimming pools and such wellness services as sauna, indoor, outdoor sports facilities, and beauty treatment services.These groups seek the so-called contrast therapies combining adrenalin increasing activities with relaxation or frequent festivals focusing on health and well-being, such as the Wanderlust. Furthermore, workplace wellness programs could be specially offered to them as well. In a 2010 research program Smith and Рисźкó identified 450 tour operators targeting this segment in the United Kingdom, Spain, Greece, Turkey, and in such emerging Asian markets as Thailand and India [5].

An increasingly high number of middle agedpatients from Western Europe and the United States travel to countries and health centres providing medical treatment combined with tourism options. Depending on the given treatment they require leisure time services and programs. As it was mentioned earlier they arrive with their families and frequently more members of the family seek medical treatment, thus there is a great need for human resources with appropriate professional and personal competence in such areas as treatment coordination and activity arrangement.

Young and middle aged families seek services simultaneously providing rest and relaxation opportunities both for parents and children. Consequently, they place a special emphasis on recreational spas offering entertainment, physical and general relaxation opportunities with unique experiences in a family-friendly atmosphere.

Furthermore, the members of the Z and Alpha generation, those born between 1996-2009 and after 2010 respectively, deserve mention as well. In the health tourism sector a younger segment emerged in the past 15 years prioritising wellness tourism options. Hungarian young adults assign high prestige to wellness tourism services [3], thus offering a potential continuation of the wellness tourism client group. Unfortunately, unhealthy diets, childhood stress, and a sedentary lifestyle have become prevalent among children and adolescents too. In Spafinder Magazine under the title «Serious Spa & Wellness for Kids» such programs are offered as meditation for children, child-oriented yoga and fitness, massages, sports camps, and organic diets.Furthermore, «Wellness and Health for Teens» [6] programs emphasize healthy lifestyles, including diets, fitness, and elimination of harmful passions or addictions along with beauty treatments and counseling on personal relationships, sexuality, and issues related to approaching adulthood. A 2017 questionnaire-based survey administered to a sample of 268 young adults in Hungary between age 14-28 concluded that despite being familiar with the requirements of a healthy lifestyle and the preservation of health, not enough attention is paid to such concerns. However, the special emphasis assigned to psychological wellbeing, happiness, and a balanced life can justify the development of programs emphasizing spirituality. Since these people specialize in festival attendance life-style related events to be discussed later can be of interest for them. It was also revealed that this age group makes travel decisions after carefuly considering the websites of the respective destinations and service providers instead of word of mouth on social media. This target group prefers cultural and gastronomical programs along with excursions and trips, thus nature and ecotourism or gastrotourism could be a potential cross-selling product.

At the same time new segments and new concepts have appeared on the health tourism market as well.

Smith-Рисźкó [5] defines holistic tourists as those who possess certain experience regarding the selected activity such as yoga, pilates, or reiki and they pursue it regularly, but they do not travel to wellness centers for improving their skills, but to find attractive and pleasant environments for their exercises. At the same time there are guests who have little knowledge about the given sessions, but they are eager to participate in such workouts. The holistic health perspective emphasizes the whole lifespan and combines the mind, the body, the emotions and all aspects of spiritual life. Providers of this type of product aimed at the achievement of physical, psychological, intellectual, and mental health offer personalized, integrated therapies promoting the appropriate life style including diet, exercise and the elimination of stress. The largest sending market is the Americans whose increasing belief in and support of alternative and holistic medicine is substantiated by the studies of Harvard Medical School and the American Holistic Health Association (AHHA).

The so-called New Age tourists traveling to locations or events connected with cultural attractions or religious significance journey for spiritual reasons. Spiritual tourists' belief in a supernatural force is coupled with a search for tranquility and internal peace. Consequently, they tend to participate in rituals striving to achieve the balance of body, spirit, and soul. They require «slow down» programs at so-called «anthropo- logical» wellness resorts such as Temas'kal and attempt to increase their knowledge of themselves along with the resolution of internal conflicts.

In addition to segmenting the health tourism market according to age and life stages researchers place an increasing emphasis on consumer behaviour, socialization,lifestyle [7], and the correlation between living conditions [3] and personal interests towards health-oriented travel [5]. The significance and role of lifestyle in consumer decisions have already been investigated in the 1960s. The respective models AIO - Activities, Interest, Opinion – and VALS - Values, Attitudes, Life-style explore, explain and analyze consumer behaviour by the help of sociological models.

Regarding the representation of health tourism's target groups, we can conclude that while in medical or curative or therapeutic tourism both sexes are represented, the wellness sector is dominated by women over 30. Thus during marketing both product development and communication efforts have to take their needs into consideration. Although fundamental social changes including female emancipation and the decline of the traditional family model contributed to the increasing role of women and has influenced tourism, men as new consumers of health tourism can be reached as well. As a result of «masculine emancipation» [8] today's men are not expected to act continuously tough and display strength and masculinity towards women and other men. Men are increasingly conscious of their appearance and their health. Male clientele can be reached via female readers. Moreover, this target group can be addressed with such call words as «stress relief, rest and relaxation, adventure, and sport» and via the combination of such activities as golf and skiing and wellness. The Spa Europa Luxury Spa & Anti-Aging Center in Calgary [9], the Nickel Spa in New York [10] or the Refinery of London (the-refinery.com/) offer exclusively «Only Man» programs via selling «For Him» packages. It must be admitted that the young age group, although presently at a small number but becoming an important potential market, cannot be attracted with any reference to diseases as they are interested in entertainment, rest and relaxation, and gaining experience and adventure as reported by The Global Spa & Wellness Summit's «SPA4U» concept [11].

Since all age groups can be targeted by service providers motivation becomes the most important criterion of marketing segmentation.

1. Research in dental tourism

It is interesting to note that on the diagram of Dental Tourists' Distribution of the World, there are more European countries than other countries, which also shows that Europe is the world's number one recipient of dental tourism.

But it is also worth mentioning that countries outside Europe are developing fast, such as India and Thailand, and with this the status of Europe and our country is getting difficult. Many will not travel this far if there are other non-European countries nearby which can provide services of similarly high quality.

As it is shown in Figure 1, Hungary is the top destination for European dental tourism among European countries.

Hungary is closely followed by Poland, which is also a significant competitor to Hungary. According to the figure above, Spain, Bulgaria and Turkey are also chosen for dental purposes in Europe, but not as much as our country. Figure 1 also shows that it is not enough to stop where we are, but we need to develop constantly, and for that the support of the state is essential and dental offices need to join with each other. If we want to keep our leading position, we must monitor our prices and services, and we cannot afford anything less. Several offices are specialized in the sale of dental treatments in Hungary, such as the Switzerlandbased Dental Travel GmbH. The company offers actual tours to Hungary for the patients with a one-week dental treatment. On their website, the show how many percent patients from Switzerland or Germany can save compared to their own prices, or those of Bulgaria and Poland ∣12]. The long-term guarantee (up to 5 years) contributes to winning German patients. Primarily they are not interested in the prices, but the quality of the service that they get from excellent specialists in Hungary.

Based on the calculations of Vezet0 Magyar Fogászati Rendel0k Egyesülete, Hungary's main sending area is the United Kingdom and Ireland, which is due to the high prices there (Fig. 2).

They are followed by Austria and France, because we have many returning guests from those countries, too. The number of tourists from Scandinavian countries is growing which has a positive impact on the balance of domestic tourism.

Many tourists from Europe come to Hungary to use dental services. The diagram about the distribution of dental tourists visiting Hungary shows that the largest percentage come from the United Kingdom to our country. They are followed by Ireland, which is surprising, as dentistry is also well developed in Ireland, and even dental tourism is characteristic there from the surrounding countries. France and Austria do not belong to the main sending countries, but the distribution of the tourists they send is still high in the average. Dental tourists from Austria are concentrated mainly in the Western part of the country.

In the first table, in the comparison of Oxygen Medical Center, we can see why it is worth to visit Hungary from Scandinavian countries.We can see from the table that while the health check and counselling is free in our country, in Norway, doctors ask for at least 350 euros just to look at the patient and give them advice, not to mention any further treatment. There is also a significant difference in the prices of more serious treatments, for example an implant in Norway costs more than three times of the Hungarian price, which can be a major reason for traveling. There is no significant difference between the prices of simple treatments, but also, we have to take notice of the quality. Last, but not least, the price of the flight ticket. Based on the prices listed on the Norwegian Airlines website, a return ticket between Oslo and Budapest costs a minimum of €300. So, if a patient would like to get an implant, it does not cost much more than €1000 including travel. It is not even the half of what the guest would pay just for the implant in Norway.

Table

Dental charge (Oxygen Medical Center 2017), euro

Patients can choose housing on their own, but many clinics offer accommodation in their own facility or they have contract with another accommodation company with discounts.

According to our survey, the number of sending countries has widened in recent years. Currently, for example Britain, Denmark and Germany are the main sending countries, but Italian, Dutch, Russian and overseas patients are also becoming more common in Hungarian dental offices. In the following diagram we can see the distribution of tourists who arrive to Hungary broken down by the sending countries. The number of guest nights what dental tourists spend in Hungary is gradually increasing, however different sources give us different data. According to the number of foreign guest nights registered by the Hungarian Central Statistical Office, the number of guest nights associated with dental treatment is estimated at 3.5 by various professional organizations. According to sources, the number of guest nights spent by dental tourists give the 56 % of all guest nights [13], while in Budapest, more than 10 % of the guests are dental tourists according toVisi [14].

The second figure illustrates how much demand and from which sending countries show up in Budapest and in the Western Hungarian region. One fifth of the total Budapest traffic is given by British patients and only a small percentage (2.5 %) travel to the Western border where 83.6 % of Austrian patients and 8.7 % of Swiss citizens are considered to be traditional. Guests who arrive for dental treatment spend 5-8 days on average for the first time in Hungary, but due to the nature of the treatment, a second, or more trips may take place, too.

According to our research, a patient pays an average of 500 pounds per day, and in one week a patient pays an average of 4,000 pounds for all the services they use in Hungary. In the patients' expenditure the largest item is the amount spent on dental treatment.The fourth chart shows the distribution of dental charges. The diagram shows that typically «large volume» interventions or more expensive routine interventions in the UK account for half of all spending. It is important to note that under a certain treatment threshold, travel is no longer worth it because the additional costs will cost the patients more than at home.

Touristic revenue opportunities from other services generated by patients arriving at dental tourism include travel agents, ticket sales and airport services, spas/wellness centres, hotel service/apartments, cultural services, sightseeing, taxi service/other means of transport, restaurants, beauty services, shopping opportunities and other health services.

1. Summary

In general, market competition is constant, and ultimately that country will be in the lead that can deliver quality services at the best price in the widest possible range. Dental tourism is also becoming popular in neighbouring countries, such as Poland, Croatia, Slovenia, Romania, while the Czech Republic and Turkey are also among the competitors of Hungary. Hungary may have a single advantage over other countries that dental tourism has begun to develop for almost 40 years in our country, so we can say that we have a great past in this area. As we have been in the market sooner than our neighbours, we have gained a better position. We have the opportunity to retain existing patients and involve new sales areas. In the market competition, that country will win which will be able to provide dental services that meet the expectations at more favourable prices.

According to the website of Reva Health, Hungary is preceded by Mexico as an active participant in dentistry, and India is also a major competitor who also receives a significant number of dental tourists annually. Considering the data of Hungary and India, Thailand and Poland are not far behind, which are also dental destinations worldwide.

In case of dental tourists, the following motivation wheel was outlined which illustrates the main factors of the patients' decision making. Generally, there is not one, but a combination of the following factors play part in making the decision [15] № According to the NHS (Dental statistics) research on the motivation of patients, the material ones are not the main factors, but rather the dissatisfaction of the local supply. However, 20 % of patients do not go for regular dental checkings because of unforeseen costs, they visit the general practitioner instead [16]. The lack of availability of the NHS and the previous negative experience in many cases would be solved by private treatment, but ultimately the price and quality of the care provided by the private sector were defined as the most motivating factor for the use of foreign treatment. Family or cultural ties also play a role in choosing a destination country. In many cases, patients, even if they are able to and willing to sacrifice money for the health of their teeth, above a certain threshold limit they are already looking for a way to save, or trying to link treatment with tourism.

References

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