**2. For a definition of "health/medical tourism"**

The term "health/medical tourism" has its origin in those countries where coverage of the cost of medical care is borne by the public or where there is no public health services guaranteed by the state.

This situation is found in several of the Western world rich countries, such as many of the major English-speaking countries (the United States of America), where, in fact, and for a very long time, you can observe a great mobility of people who need medical care and that move within their own country, or even abroad, to the medical service research that, at least of equal quality, offers a more advantageous cost.<sup>2</sup>

However, in countries like Italy where, as always, there is a national health service, that is, where the state offers its citizens the opportunity to care for free or at low cost, and where all the different types of medical services are, or should be, guaranteed locally or, in any case, in the vicinity of the closest spatial urban centers, the health tourism expression has never been, and still it is not today, similarly applicable, on the contrary, said in these terms, it seems inappropriate, that is, because the main reason for medical mobility is determined or because the severity of the person's health situation is such that to resolve it, he must move toward national public specialized centers of medical excellence or because the place where he lives the public health presents evident criticality in the quality of medical services.

Obviously, the reference just mentioned on the Italian situation does not apply to all citizens, in the sense that existing excellent medical services are provided in private health facilities, people who can afford it, that is, those with greater economic capacity, they may decide to opt for this type of medical facilities and not for those public ones.

<sup>1</sup> Paragraphs "Introduction"' "For a definition of health/medical tourism" and "Conclusions" are by Tullio Romita; Paragraphs "The so-called 'health tourism' market" and "Low-cost medical tourism of Italians" are by Antonella Perri. 2 It is also fair to add that mobility is not only directed to having a quality medical service at or higher, but also to search for the so-called "second opinion" as a confirmation of a diagnosis or treatment.

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,<sup>3</sup> 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 which6 : "Tourism is a social, cultural, and economic phenomenon, which entails the movement of people to

4 In this regard compares, for example, Refs. [2–4].

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

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

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

The term "health/medical tourism" has its origin in those countries where coverage of the cost of medical care is borne by the public or where there is no public health services guaranteed

This situation is found in several of the Western world rich countries, such as many of the major English-speaking countries (the United States of America), where, in fact, and for a very long time, you can observe a great mobility of people who need medical care and that move within their own country, or even abroad, to the medical service research that, at least of equal

However, in countries like Italy where, as always, there is a national health service, that is, where the state offers its citizens the opportunity to care for free or at low cost, and where all the different types of medical services are, or should be, guaranteed locally or, in any case, in the vicinity of the closest spatial urban centers, the health tourism expression has never been, and still it is not today, similarly applicable, on the contrary, said in these terms, it seems inappropriate, that is, because the main reason for medical mobility is determined or because the severity of the person's health situation is such that to resolve it, he must move toward national public specialized centers of medical excellence or because the place where he lives

Obviously, the reference just mentioned on the Italian situation does not apply to all citizens, in the sense that existing excellent medical services are provided in private health facilities, people who can afford it, that is, those with greater economic capacity, they may decide to opt

Paragraphs "Introduction"' "For a definition of health/medical tourism" and "Conclusions" are by Tullio Romita; Paragraphs "The so-called 'health tourism' market" and "Low-cost medical tourism of Italians" are by Antonella Perri.

It is also fair to add that mobility is not only directed to having a quality medical service at or higher, but also to search

the public health presents evident criticality in the quality of medical services.

for this type of medical facilities and not for those public ones.

for the so-called "second opinion" as a confirmation of a diagnosis or treatment.

transport.

tourism market.

2 Advances in Health Management

by the state.

1

2

medical tourism of Italians.1

**2. For a definition of "health/medical tourism"**

quality, offers a more advantageous cost.<sup>2</sup>

<sup>3</sup>For a discussion about the cross-border healthcare scheme, see Ref. [1].

<sup>5</sup> The UNWTO acronym stands for "United Nations World Tourism Organization"; the corresponding Italian acronym is OMT (Organizzazione Mondiale del Turismo).

<sup>6</sup> 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].

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

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

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

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

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

regardless the motivation that determines the journey.

4 Advances in Health Management

to the absence of at least one night in an accommodation facility.

almost an oxymoron. Here, we try to explain what we mean.

certainties.

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.

<sup>7</sup> An interesting aspect that should be investigated, is that inherent to the paradox mentioned by Lunt et al. [9] that one side he talks about the voluntary nature of the trip, but on the other, highlights the preference of patients to be treated close to home. This in our view would justify an attitude obvious and immediate that equal of quality medical, patients, even for economic reasons, tend to choose the closest specific center.

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":


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
