**3. The so-called "health tourism" market**

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

• With the "medical trip" expression, we could indicate all those travel experiences that individuals make because in any case obliged, the motivation of the travel to seek health care controls and/or medical treatment that they are necessary to the control or to the resolution of a disease, though the related medical and health care services are available at the place

• With the "wellness tourism" expression, we could, however, indicate all volunteer's trips that people make for not essential medical services but for the care of the psycho-physical wellness of their appearance. Among other things, it is worth noting that in the Italian case, the public national health service does not recognize the costs of nearly all of these treatments, which are therefore the sole responsibility of the citizen, and even if the choice of the medical structure in which "you receive care" is important, it is important too, the identification of the place where to go that sometimes convinces in particular the offer of

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

"tourist" services associated, in other words to mix business and pleasure.

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

further expressions: "medical trip" and "wellness tourism":

where he usually lives;

6 Advances in Health Management

Evaluate the value of world market of so-called "health tourism" is not easy for two reasons.

The first one is a question of conceptual character. As we wrote before, to establish with reasonable accuracy what actually "health tourism" is, it is possible only when you come to a shared definition of the meaning. However, for the purposes of this paper, we assume that health tourism like all mobility that is determined by motives that concern as well as medical care dedicated to the more general welfare of the people. The second reason is the scarcity of systematic studies of this type of mobility, for which you will use what we currently have.

Bearing in mind the considerations just made, we say that already about 10 years ago, the American company Deloitte Research [10] predicted a rosy future for the US health tourism, which it imagined would touch the six million citizens compared to about eight hundred thousand in 2007, for a global turnover estimated at several billion dollars annually.

The same Deloitte [11], in a later study calculated "… that every year seven million people in the world travel because of health reasons, already generating a turnover of 100 billion dollars, which will become 150 in 2018" [12]. In addition, according to another study dated 2016, "… the revenue generated from medical tourism already amounted to 12 billion euro in Europe … Italy has a market share of 2 billion, which could reach 4, by implementing the "provision of health and tourism services offered to foreigners."<sup>9</sup>

The so-called health tourism is today a social and economic phenomenon of great importance in fact recently, and for the first time in one of the most important fairs of world tourism, which was the FITUR 2015, a specific space it has been reserved right to health tourism.

However, the Italian Association for Medical Tourism Development (IAMT) has published on its website [13], a brief illustration of the background of health tourism. In particular, the variables that determine the majority of the customer mobility flows are the quality of the delivered treatments; better access to health services; the absence of waiting lists; the ability to bind to a health need for the satisfaction of a tourist needs; travel opportunities; the cost of treatment, which is a significant variable for a given segment of the market; the confidentiality, especially for esthetic interventions. In addition, with regard to the health tourism numbers, it notes that about 15 million tourists patients in 2017 will decide to resort to medical treatment abroad, and that the major destinations of health tourism for many tourists are Costa Rica, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thainlandia, Turkey, and United States of America.

<sup>8</sup> In this paper, our intention is to consider the tourist as a person with an emphasis on the human and the emotional aspect. Not included in the health consumer commodification process, but as a person who seeks a better state of health. 9 Forum on the Internationalization of the Italian Health 2016, Rome; Report Observatory Private Consumption in Health (OCPS), SDA Bocconi, Milan.

There are more than 200,000 Italians who are traveling because of sanitary issues. At least, a quarter of this, 200,000 Italians ask for medical care dentistry. Most treatments in specialized health tourism dental are in Eastern European countries, Croatia, Hungary, and Romania (with Albania that's growing up). For the Italians, it is easy to get there in these countries, especially if they live near the airport. It is quite clear that these are countries where the cost of dental care is much lower than in Italy. Often the dentists (in these countries) have even studied abroad. The promotion of health treatment is very aggressive and aims almost exclusively on the Web support; in addition, all medical treatments are combined, with the basic tourist services like accommodation, food, shuttle service, etc. and excursions in the area who takes care to these tourists who speak Italian.

Precisely of this type of health tourism, we will deal in the next section.
