CC BY
63MARKETS AND COMPETITION
9
GAYANE TOVMASYAN
PhD in Economics, Associate Professor, Senior Researcher at "Amberd" Research Center of ASUE, Lecturer at Armenian State University of Economics and Pubic Administration Academy of the RA
https://orcid.org/0000-0002-4l3l-6322
HEALTHCARE TOURISM IN ARMENIA: OPPORTUNITIES AND PERSPECTIVES OF DEVELOPMENT
People have begun to travel for healthcare purposes since ancient times. Nowadays, healthcare tourism is one of the fast-developing industries in the world. Armenia also has opportunities for healthcare tourism development. People mostly come to Armenia for dental treatment, cosmetic surgery, etc. The paper focuses on some international trends of medical tourism development, analyzes medical and wellness tourism resources and current state. With the help of SWOT analysis evaluations, the best strategy for healthcare tourism development, which is an aggressive strategy, was defined. Based on the results, some steps were offered in these directions: improving the statistical recording and legislation of healthcare tourism, improving the marketing activities of the sphere, increasing the competitiveness of medical services and the demand for them, improving the business and investment environment of healthcare tourism, and scientific support for the organization of treatment and tourism development. The research results may be useful for state agencies, private sector, etc. for elaborating and accomplishing healthcare tourism development plans.
Keyword: healthcare tourism, wellness, medical treatment, resort, SWOT, strategy, Republic of Armenia.
JEL: L83, II5
DOI: 10.52174/1829-0280_2021 _5_l 07
Introduction. Travelling for health care has a long history of development. Health or medical tourism is the international travel for the purpose of receiving medical care. Many patients travel because the procedures they seek can be performed in other countries at relatively low cost or without the delay and inconvenience of being placed on a waiting list. In addition, some patients travel to specific destinations to undergo procedures that are not available in their home country.1
According to Medical tourism market report, the global medical tourism market size accounted for $104.68 billion in 2019, and is projected to reach $273.72 billion by 2027. In terms of volume, the global medical tourism market accounted for 23,042.90 thousand patients in 2019, and is projected to reach 70,358.61 thousand patients by 2027. On the basis of treatment type, the cancer treatment segment accounted for the highest medical tourism market share in 2019 due to surge in incidence of cancer worldwide. Besides, key market segments are: dental, cosmetic, cardiovascular, orthopedic, neurological, cancer, fertility treatments, and others. Unfortunately, COVID-19 outbreak had varying degree of negative impact on all segments of medical tourism market. For instance, elective treatments such as dental treatment, cosmetic treatment and others suffered a greater impact.2
Armenia possesses great opportunities for developing health tourism in Armenia. People mostly come to Armenia for plastic surgery, dental, gynecological services. Besides medical treatment, many people come also for spa-resort services. Armenia has 10 resort zones which have natural curative resources. During Soviet era, Armenian resorts and sanatoriums were very popular among international tourists. Now there are many problems for medical and spa-resort tourism development. There are no statistical data about the number of medical and spa-resort tourists, their country of origin, age, gender, preferences, types of medical procedures, etc. Besides, there is a need to promote health care tourism product at international level, increase the quality of services, etc.
The research aims at exploring the main issues and prospects for developing health tourism in the country. For that purpose, some literature sources on healthcare tourism were examined, also the international trends of medical tourism development in different countries were explored, then the medical and spa-resort tourism sphere in Armenia was analyzed, and some recommendations were made.
Literature review. According to the Medical tourism association, 'medical tourism is the globalization phenomenon where people who live in one country travel to another country to receive medical, dental, and/or surgical care. Medical travelers often engage in medical tourism to save money, but this does not mean they are sacrificing quality for savings. Medical tourists typically receive
1 Rogers, K., (n.d.) Medical tourism, Britannica. https://www.britannica.com/science/medical-tourism
2 Gill, S., & Sinha, S. (2020). Medical tourism market by treatment type (Dental treatment, cosmetic treatment, cardiovascular treatment, orthopedic treatment, neurological treatment, cancer treatment, fertility treatment, and others): Global opportunity analysis and industry forecast, 20192027. https://www.alliedmarketresearch.com/medical-tourism-market
equal or greater care than they would have in their own country, and are traveling for medical care because of affordability, or better access to a higher or more specialized quality of care'.3
Henderson has provided an overview of the types of treatments that can be included under the broad area of healthcare tourism.4
• Illness. Most of what is commonly referred to as medical tourism is directed towards the treatment of illness, and includes surgical, ophthalmological and dental operations, and may include overnight stays in a hospital or similar accommodation with nursing care.
• Wellness. With the current trend towards healthier lifestyles, there is an increasing amount of travel directed towards wellness, or the prevention of illness. These include trips for spa, thermal, and water treatment, massage, drug rehabilitation and slimming treatments.
• Enhancement. Increasingly people are turning to medical means of enhancing their appearance. This may include plastic surgery or cosmetic surgical treatments.
• Reproduction. Many people travel for the purposes of fertility treatment or giving birth.
Thus, the main sectors within the overall medical and healthcare tourism market are: medical tourism (illness), beauty treatment and spas (wellness), cosmetic tourism (enhancement) and reproductive tourism.5
According to Garcia-Altes, the growth of health tourism is connected with the changes of demography and lifestyle, as well as with the increasing demand for healthcare services in major source markets. He also mentions four factors which are important to make decision about traveling abroad for medical care. These factors are: price, quality, availability and timeliness.6
Ehrbeck et al. mentioned five factors which promote medical tourism by conducting a survey among 49,980 patients: most advanced technology (40%), better-quality care for medically necessary procedures (32%), quicker access to medically necessary procedures (15%), lower-cost care for medically necessary procedures (9%), and lower-cost care for discretionary procedures (4%).7
Crooks et al. identified four main themes that summarize what is known about the patient's experience. These themes are characterized by a focus on: (1) patients' decision-making in terms of push and pull factors, as well as the
3 Medical tourism, What is medical tourism, (n.d.) https://www.medicaltourism.com/frequently-asked
4 Henderson, J.C., (2004) Healthcare tourism in Southeast Asia. Tourism review international, 7, pp. 111-122, extracted from Medical Tourism: a global analysis, Tourism Research and Marketing, (2006), London, pp. 11-13,
https://www.researchgate.net/publication/345763075 Medical tourism a global analysis
5 Medical tourism: a global analysis. (2006) Tourism research and marketing, London, https://www.researchgate.net/publication/345763075 Medical tourism a global analysis
6 Garcia-Altés, A., (2005) The development of health tourism services. Annals of tourism research, Volume 32, Issue 1, pp. 262-266, doi:10.1016/j.annals.2004.05.007
7 Ehrbeck, T., Guevara, C., Mango, P., (2008) Mapping the market for medical travel. McKinsey Quarterly: 1-11, https://www.mckinseyquarterly.com/Mapping the market for travel 2134, extracted from Hwang, S., Lee, D., Kang, C., (2018) Medical tourism: focusing on patients' prior, current, and post experience, International journal of quality innovation, 4, 4, https://doi.org/10.1186/s40887-018-0024-2
consultation of information; (2) motivations related to procedure, travel, and cost; (3) risks associated with patients' health, travel, and pre- and postoperative conditions in the home country; and (4) first-hand accounts of the positive and negative components of medical tourism, sensationalized issues, and post-recovery life.8
Patients' experience in medical tourism pre-search (reputation, searching information, and communication) has a partially positive effect on their experience (costs, care quality, and supporting system and/or information) and patients' current experience during the medical tour process has a positive effect on post-experience (relationship building, recommendation, and feedback). 9
Medical tourism generally involves transporting patients from developed countries to developing countries where they can get treated at lower expense.10
Drivers of medical tourism include globalization - economic, social, cultural and technological. Many domestic health systems are undergoing significant challenges and strain - tightened eligibility criteria, waiting lists, and shifting priorities for health care may all impact on consumer decision making.11
According to Runnels and Carrera the decision to engage in medical tourism is more complex, driven by patients' needs, the nature of services sought and the manner by which treatment is accessed. They propose a sequential decision-making process in opting for or against medical care abroad, and engaging in medical tourism, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care.12
According to 'Medical tourism: A prescription for a healthier economy' report of 2019 by World Travel and Tourism Council, which includes the results of analyses conducted in 115 countries, the international spending on medical tourism products and services grew by 4.6 times between 2000 and 2017, increasing from $2.4 billion to $11 billion. This growth resulted in spending on medical tourism reaching 1.2% of international visitor spending in 2017 compared to 0.6% in 2000. The report also presents the most efficient policies which different countries apply for promoting medical tourism: establishing smart regulation and recognized accreditation/certification of medical
8 Crooks, V., Kingsbury, P., Snyder, J., Johnston, R., (2010) What is known about the patient's experience of medical tourism? A scoping review. BMC Health services research, 10(266), pp. 1-12, https://doi.org/! 0.1186/1472-6963-10-266
9 Hwang, S., Lee, D., Kang, C., (2018) Medical tourism: focusing on patients' prior, current, and post experience, International journal of quality innovation, 4, 4, https://doi.org/10.1186/s40887-018-0024-2
10 NaRanong, A., & NaRanong, V., (2011) The effects of medical tourism: Thailand's experience, Bull world health organ, 89, pp. 336-344, doi:10.2471/BLT.09.072249,
https://www.scielosp.org/article/ssm/content/raw/?resource ssm path=/media/assets/bwho/v89n5/v 89n5a09.pdf
11 Lunt, N., Smith, R., Exworthy, M., Green, S. T., Horsfall, D., Mannion, R., (2011) Medical Tourism: Treatments, markets and health system implications: A scoping review, OECD, https://www.oecd.org/els/health-systems/48723982.pdf
12 Runnels, V., & Carrera. P.M., (2012) Why do patients engage in medical tourism?, Maturitas, Volume 73, Issue 4, pp. 300-304, https://doi.org/10.1016/j.maturitas.2012.08.011
practitioners and facilities; developing enabling visa facilitation policies which support the development of this sub-sector; defining the skills gap and developing trainings to enhance the talent; designing and implementing targeted marketing strategies; creating financial incentives to attract investment into the sub-sector.13
One of the leading international health care accreditation organizations is the Joint commission international (JCI), which works to improve patient safety and the quality of health care by offering education, publications and advisory services. In more than 100 countries, JCI partners with hospitals, clinics, academic medical centers, health agencies, government ministries and academia to promote rigorous standards of health care.14
According to the Medical tourism index, which assesses the attractiveness of countries for medical travel, a country's economy and public image, healthcare costs, and quality of care are the major factors that drive medical tourism growth in a destination. Using these metrics, here are the top 10 medical tourism destinations in the world: Canada, Singapore, Japan, Spain, UK, Dubai, Costa Rica, Israel, Abu Dhabi, India. Canada attracts more than 14 million medical tourists only from the USA each year. Seeking health care in Singapore saves a patient 25% to 40% of what they would have spent on the same services in the United States. For example, heart bypass surgery costs $140,000 in the US and $25,000 in Singapore. A hip replacement surgery which costs over $45,000 in the US can be done for about $13,000 in Singapore, and in Japan it costs $4,126. Spain attracts international tourists for advanced orthopedic, cosmetic, and dental procedures. Cosmetic procedures such as face lift and breast augmentation that cost as much as $15,000 in the US cost an average of $5,000 in Spain. India has an expanded visa policy that eases travel for medical tourists. It allows patients to stay up to 60 days and also offers a medical attendant visa for blood relatives that wish to accompany the patient. The Indian government launched a medical tourism portal15 to provide patients with access to their network of healthcare facilities and a list of medical services available in the country.16
Research methodology. One of the main research methods for this article was SWOT analysis. SWOT (strengths, weaknesses, opportunities, and threats) analysis is a method used to evaluate the internal and external factors, as well as current and future potential of development. For conducting SWOT analysis, the
13 Medical tourism: A prescription for a healthier economy, (2019) WTTC, URL: https://wttc.org/Portals/0/Documents/Reports/2019/Medical%20Tourism-Nov%202019.pdf?ver=2021-02-25-182803-880
14 Joint commission international, (n.d.) https://www.jointcommissioninternational.org/, extracted from Medical tourism: A prescription for a healthier economy, (2019) WTTC, URL: https://wttc.org/Portals/0/Documents/Reports/2019/Medical%20Tourism-Nov%202019.pdf?ver=2021 -02-25-182803-880
15 India Health Care, (n.d.) http://www.indiahealthcaretourism.com/
16 Stefano, R-M., (n.d.) Top 10 medical tourism destinations in the world, Medical tourism magazine, https://www.magazine.medicaltourism.com/article/top-10-medical-tourism-destinations-world
strengths, weaknesses, opportunities, and threats of medical and spa-resort tourism development in Armenia were explored.
The methodology of SWOT analysis is the following:
S After listing the key internal and external factors as strengths and weaknesses, opportunities and threats, each factor is given a weight that ranges from 0.0 (not important) to 1.0 (very important). The sum of all weights assigned to the factors must equal 1.0.
S Then a rating between 1 and 4 is assigned to each key internal and external factor (rating =1 means that the factor is fragile and rating =4 means that the factor is robust).
S By multiplying each factor's weight by its rating, a weighted score is determined.
S After that, the weighted scores are summed for each variable to determine the total weighted score, the highest possible total weighted score is 4.0 and the lowest possible total weighted score is 1.0. The average total weighted score is 2.5.17
The factors of SWOT were selected based on author's analyses, also based on the discussions with sphere professionals. The discussions were done through group brainstorming methods.
The following methods and techniques of group brainstorming were used: ordinary brainstorming, reverse brainstorming, role storming, mind mapping, brainwriting, starbusting. The total number of experts involved in the discussions was 20. The latter are tourism sphere professionals, researchers, and organizers of health care services, representing both public and private sectors. The discussions were conducted to find out the issues in different spheres of healthcare tourism system and to provide solutions to them.
The method of individual brainstorming was also applied. Individual brainstorming is the most effective when there is a need to solve a simple problem, generate a list of ideas, or focus on a broad issue. Thus, it was very useful here to generate a list of ideas on healthcare tourism development issues.
With the help of SWOT results, internal-external matrix and strategy space matrix were composed for defining the best strategy for healthcare tourism development in Armenia.
Based on the analyses, directions of improvement were suggested, with a range of steps, which may be basis for developing healthcare tourism development strategy for the RA.
Analysis
Medical tourism in Armenia.
Medical tourism has development opportunities in Armenia. The most popular areas of medical tourism in Armenia are plastic surgery (especially nose), dental, gynecological and trauma services. Moreover, the tourists are not only Armenians of foreign origin, but also foreigners from Europe, Iran and the UAE.
17 David, F.R., (2011), Strategic management: Concepts (13th ed.). Prentice Hall, New Jersey, pp. 60191, http://irresearchers.ir/upload/docs/StrategicManagementDavid.pdf
There are no exact statistics on the number of tourists who come to Armenia for medical treatment. In 2019, 0.5% or about 2751 tourists who stayed in hotel facilities came for medical purposes, and in 2020 - 0.4% or 1500 tourists. But it is possible that the tourists did not stay at hotels, but stayed at rented apartments or at relative's house.
Table 1
Incoming tourist visits to Armenia by purpose, 2017-2020 18
Year I 2017 2018 I 2019 I 2020 I
Incoming tourists 1494779 1651782 1894377 375216
from which tourists who stayed at hotel facilities 264702 307473 550289 97550
by purpose 100% 0*2 Q0/ 100% 07 0/ 100% 1 qo/ 100% 1 c 00/
business rest and leisure medical treatment 23,9% 52,8% 27,3 % 48,8% 1 A0/. 15.9% 55.4% n MZ 15,8% 50,3% O A0/.
other 0,2% 23,1% 1,4% 22,5% 0.5% 28.2% 0,4% 33,5%
From domestic tourists only 53500 traveled for medical treatment in 2020, but this again refers to those who stayed at hotel facilities.
In this regard, it should be noted that the division for treatment is general, i.e. it may include tourists travelling for medical purposes, also for spa-resort, wellness services.
The investigation of statistical data (from 2001 till today) on the number of incoming and domestic tourists indicate that the ratio of the number of tourists with the purpose of medical treatment in the whole number of tourists has not changed dramatically, this means that medical purpose still has very little share in the above mentioned classification of travelling purposes. For this reason, the data are not presented for a long period of time, but only for last 4 years as descriptive statistics about the travelling purposes of tourists.
Unfortunately, there are no more comprehensive statistics on travelers by regions, by type of hotel facilities, by nationality, country of origin, by length of stay, by type of services required.
It should be noted that the Ministry of Health of the RA does not possess any data on the number of tourists arriving for medical purposes, what medical services they use, etc. Public or private medical institutions also do not publish the numbers of medical tourists.
In 2013, as a result of the surveys conducted among the incoming and outgoing tourists at the RA border crossing points, it became clear that the aim of the visit of 8.47% of the 22,100 surveyed incoming tourists was treatment. About 80% of those who came for treatment were women, about 60% were 36-
18 The Statistical committee of the RA. (2019, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 19a 421.pdf
The Statistical committee of the RA. (2020, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 20a 421.pdf
The Statistical committee of the RA. (2021, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 21a 421.pdf
63 years old, and 30% - 18-35 years old19.
Table 2
The number of domestic tourists in Armenia by purpose, 2017-2020 20
Year I 2017 I 2018 I 2019 I 2020 I
Domestic tourists staying at hotel facilities, 1086707 1092322 1544600 1045756
by purpose
business 252787 207761 280542 150649
rest and leisure 742188 /IOCCO 781668 COOOQ 1112305 765100 cocfin
medical treatment other 43558 48174 58339 44554 52006 99747 53500 76507
In 2019, there were 494 primary health care institutions in Armenia, 138 of which were in Yerevan, also 125 hospitals, 53 of which were in Yerevan. The number of doctors in all specialties (including dentists) in 2019 was 13958, of which 9764 in Yerevan21.
According to the RA tourism strategy draft for 2021-2030, among the main types of tourism is medical / spa-resort tourism. According to the draft strategy, the tourists arriving for medical / spa-resort tourism are mainly Armenians from the Diaspora, and Russians, who arrive in Armenia for about 2 weeks for sanatorium treatment, dentistry, plastic surgery. Medical and spa-resort tourism together make up 2% of the entire tourism industry of Armenia.
According to the draft of the strategy, the sphere of medical tourism in Armenia, which is concentrated in Yerevan, is one of the smallest spheres of tourism. Medical travelers usually choose to travel when they can save more than 30% of their expenses. For example, plastic surgery in Armenia is more affordable than in Europe, laser surgeries are 50% cheaper in Armenia than in Canada. Medical tourists, who are mainly Russians and Armenians of the Diaspora, usually come to Armenia for 10-15 days, most often for dental services and plastic surgery (65% of tourists come to Armenia for dental services). The recovery period usually lasts 7-8 days. After tourists receive their primary treatment, they usually take tours within the country. Tourists who arrive for dental purposes, in particular, are considered full-fledged tourists, as they do not need further medical examination after receiving treatment.
19 Report on the results of the sample survey on international visits at the border crossing points of the Republic of Armenia conducted in 2013, (2014) Yerevan, pp. 23-27, https://www.mineconomy.am/media/2076/1456.pdf
20 The Statistical committee of the RA. (2018, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 18a 422.pdf,
The Statistical committee of the RA. (2019, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 19a 422.pdf,
The Statistical committee of the RA. (2020, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 20a 422.pdf,
The Statistical committee of the RA. (2021, January). The socio-economic situation in the RA. https://www.armstat.am/file/article/sv 01 21a 422.pdf
21 Andresayan, D., Bazarchyan, A., Matevosyan, M., Mirzoyan, L., Muradyan, G., Simonyan, A., Simonyan, S., (2020) "Health and healthcare'' Statistical yearbook, Armenia 2020, Yerevan. National institute of health named after academician S. Avdalbekyan", CJSC, Ministry of Health of the Republic of Armenia, pp. 174, 179, 218, URL: https://nih.am/assets/pdf/atvk/9cebab1c6da9fe5f6dc32d31d3405803.pdf
According to the draft of the strategy, medical tourism in Armenia is considered to be one of the narrow areas of the sector, which seems promising for growth, but to a small extent, taking into account the need to invest in additional infrastructure, marketing and travel facilitation. Armenia offers high quality services. Many doctors are trained abroad and have the reputation of being properly qualified doctors. There is also modern high-quality equipment in Armenia. Combining these qualities with the fact that most medical tourists are able to enjoy a rest during visit, we can say that Armenia has good opportunities for possible growth in this area.22
It is necessary to present the comparative values of several medical services in Armenia and in the world. According to the Bookimed international medical tourism online platform (which summarizes the services of 735 medical institutions in 32 countries, with the help of which tourists can find a suitable country, hospital, doctor), the average prices of several medical services in the world and in Armenia are presented in table 3.
Table 3
Costs of medical services in Armenia and in the world in June 2021
RA (AMD) RA (US dollar23) Average cost of735 hospitals included in Bookimed online portal (dollars)24
Coronary artery bypass grafting Facelifting surgery 250000025 35000026 120000-40000027 28000028 100000-35000029 4883 4400-55000 109-28032 168-2253 850-12906 380-29333
Dental implant 684 234-781 RATI
Rhinoplasty (nose) Liposuction 547 195-684
As can be seen from the table, nasal rhinoplasty price is lower in Armenia, and other services are more affordable than the world average prices.
Spa-resort (wellness) tourism in Armenia
Along with medical tourism, it is necessary to discuss the prospects for the development of spa-resort or wellness tourism in Armenia, as it is also included in the healthcare tourism system.
Spa-resort tourism is a temporary exit from the place of permanent residence of people for sanatorium-rehabilitation purposes. There is a special balneological tourism, the essence of which is the adoption of mineral water,
22 Draft of the strategy for the development of tourism in Armenia for 2021-2030, https://www.e-draft.am/projects/2790/about
23 Currency: 1$ = 512,01 AMD, as of 23.06.2021
24 Bookimed, Diagnostic tests and treatment procedures. https://en.bookimed.com/prices/
25 Erebouni medical center, Cardiovascular surgery department. https://www.erebunimed.com/arm/department/76
26 Erebouni medical center, Plastic surgery and microsurgery department. https://www.erebunimed.com/arm/department/95
27 Medesy, Price - stomatology. https://www.medesy.am/arm/Prices_Stomatology.html
28 Erebouni medical center, Plastic surgery and microsurgery department. https://www.erebunimed.com/arm/department/95
29 Sirmed, Plastic surgery services. http://sirmed.am/am/plastic-surgery/
medical-rehabilitation procedures, which is carried out under medical supervision.30 Thus, it can be said that spa-resort tourism is the type of tourism, which is based on visiting sanatoriums for sanatorium treatment and rest.
Armenia has great capability for spa-resort tourism development. The scientific research institute of spa treatment and physical medicine of Health ministry of the RA has differentiated 10 resorts in Armenia, all of which have natural curable resources for spa-resort tourism development (hot springs of mineral water (more than 200), curable mud and peat, favorable climatic conditions for climate therapy). These resorts are Arzni, Dilijan, Hankavan-Marmarik, Bjni-Arzakan-Aghveran, Tsagkhadzor, Stepanavan-Gyulagarak, Syunik, Lori, Sevan and Jermuk.31 It is estimated that about 22 million litre mineral water can be derived from springs of mineral water in Armenia daily.32
Armenia's main resort zones and their primary natural curative resources
are:
1. Arzni balneological resort, the vital healthful factors of which are the comfortable landscape-climatic conditions and medicinal, mineral waters.
2. Dilijan mountain-climatic, balneological resort, which provides essential remedial resources such as favorable mountainous and forest climatic conditions and cold, carbonaceous, curable mineral waters.
3. Hankavan-Marmarik balneological resort, the fundamental medicinal sources of which are the comfortable landscape-climatic conditions of high mountains, fresh and oxygen-rich air, hot, carbon dioxide mineral waters.
4. Bjni - Arzakan - Aghveran balneological resort, the central restorative factors of which are favorable mild climate, rich forest coverage, mineral springs of many different physical, chemical, gas composition.
5. Stepanakert-Gyulagarak mountain-climatic, balneological resort, which offers leading curative components namely moderately cold, forest climate, rich vegetation, woodland, clean air, carbon dioxide mineral waters.
6. Tsakhkadzor mountain-climatic resort, the particular curing elements of which are favorable climate of mountains and forests, the availability of huge forest coverage and mountain meadows and a high concentration of oxygen in the fresh air.
7. Syunik mountain-climatic resort with its specific and favorable climate, mineral waters.
8. Lori resort, which comprises supportive mountain-forest climate, mineral waters, healing muds and turfs.
9. Lake Sevan resort with its amazing landscape-climatic conditions, mineral waters, healing muds and turfs.
30 Loyko, O., (2005) Tourism and hospitality: textbook. Tomsk: TPU publishing house, p. 68, (in Russian)
31 Tovmasyan G., (2020) The problems of tourism development in the Republic of Armenia (monograph), Yerevan, Meknark LLC, pp. 168-177 (in Armenian)
32 Mineral water usage estimation, (2011) http://www.tert.am/am/news/2011/09/07/jermuk/
10. Jermuk balneological, climatic resort which includes hot carbon mineral
waters and high mountain-forest climate.33 Armenian resorts are surely worth being compared with world famous resorts and Armenia has the chance to become a famous regional and international resort tourism center due to the country's significant traditions of spa-resort tourism. The water of Jermuk is compared with the mineral curable water of Karlovy Vari in the Czech Republic and with the water of Zheleznovodsk in Russia. The natural curable resources of Dilijan are compared with the famous resorts Borjomi, Abastuman, Kislovodsk, Esentuki, and Pyatigorsk. Arzni is a unique resort in the region for the heart disease treatment.34
In Armenian sanatoriums many diseases are treated such as nervous, urinary, gynecological and respiratory systems, metabolic disorders, the first and second degrees of hypertension, atherosclerosis of blood vessels, brain blood circulation irregularities, the consequences of stroke, radiculitis, bronchial asthma, etc.
Unfortunately, there do not exist sanatoriums in all resorts. There are only 14 sanatoriums in Armenia, some of which are not in good conditions and need to be reconstructed.
The license of sanatoriums in the Republic of Armenia is issued by the Ministry of Health. Currently, the following 14 sanatoriums operate in Armenia: Jermuk World, Gladzor, Armenia, Jermuk N 1, Olympia, Ararat Mother and Child in the city of Jermuk, Ripa in Tsakhadzor, Arevik in Sevan, Arzni sanatorium, Khotorjur in Hankavan, Gandzaghbyur in Arzakan, Impuls and Mountainous Armenia in Dilijan, and Vanadzor sanatorium.35
However, there are no separate statistics on the number of spa-resort tourists, which countries they come from, what services they use.
According to the draft of the Tourism development strategy for 2021-2030 of the RA, the main engine of the spa-resort tourism is the domestic market and Russian visitors as the main international market (80% of tourists are Armenians and 20% are foreigners). There is a possibility of further growth of spa-resort tourism in the domestic tourism market. Local tourists are a potential source of demand for spa-resort tourism, which could lead to a gradual increase in the sector, taking into account both the increase in spa offerings and the increase in
33Harutyunyan, B., (2010) Atlas, climate and natural therapeutic resources of Armenia. Yerevan: STPM, p. 124-133, (in Armenian).
Tovmasyan, G., (2016) Spa and wellness tourism advancement in the Republic of Armenia, pp. 3439, XIV Международная научная конференция "Актуальные научные исследования в современном мире", Переяслав-Хмельницкий, Украина, Выпуск 6(14), Часть 2. Tovmasyan, G., (2016) The main ways of spa-resort tourism advancement in Armenia, monograph, LAP Lambert Academic Publishing, 52 p.
Tovmasyan, G., (2020) The problems of tourism development in the Republic of Armenia (monograph), Yerevan, Meknark LLC, pp. 168-177 (in Armenian)
34 Arzni sanatorium, http://www.arzniresort.am/am
35 Source: Data provided by the Licensing department of the Ministry of Health of the RA
social packages, which make treatment more accessible to Armenians. Spa-resort tourism can offer opportunities for tourists in all seasons.36
SWOT analysis of healthcare tourism in Armenia
In order to find out the healthcare tourism development problems in Armenia, SWOT analysis was performed. For that purpose, the strengths and weaknesses, opportunities and threats were discussed, dividing them as internal and external environment factors.
Table 4
Internal factor evaluation (IFE)
N Factors of internal environment Weight Rating Weighted score
1 2 Strengths Availability of 10 resort zones Resources for organizing climatotherapy and balneology 0.058 4 0.233 0.047 4 0.186
3 Extensive list of diseases treated in sanatoriums 0.058 3 0.174
A A 1 UT+ fU" Li IT A A + f\ nKQ Q n 17/1
4 5 Availability of highly qualified doctors Affordable prices for medical services for those coming from 0.058 4 0.233
C abroad n 11A
6 Extensive list of medical services U.WJO O U.l/t
7 8 9 Existence of great resources for organizing recreational tourism in Armenia Existence of the Armenian Diaspora Availability of a social package for the RA citizens 0.058 4 A 4 0.233
0.058 0.047 3 0.233 0.140
Total 0.5 1.779
Weaknesses
1 Incomplete statistical accounting 0.058 4 0.233
2 Lack of strategies for the development of medical and spa tourism 0.058 4 0.233
3 Lack of international accreditation of the RA medical institutions 0.058 4 0.233
4 Poor presentation and promotion abroad of medical and resort tourism resources 0.058 4 0.233
5 6 7 8 9 Lack of a unified information-booking portal for medical- sanatorium tourism services for tourists Not all resorts have sanatoriums High prices for medical services for the RA citizens Lack of compulsory medical insurance Low level of organization of spa-resort and medical tourism education 0.058 H H/17 4 O 3 0.233 n 1 /in
0.047 0.058 f) C\A7 4 O 3 0.I40 0.233 f) 1AD
0.047 0.058 3 0.140 0.174
Total 0.5 1.849
The total weighted score of strengths and weaknesses is 3.628.
36 Draft of the strategy for the development of tourism in Armenia for 2021-2030, https://www.e-draft.am/projects/2790/about
Table 5
External factor evaluation (EFE)
Factors of external environment
Weight Rating
Weighted
1 2 3 A Opportunities Creation of a unified information portal on medical and health-resort services International accreditation of medical institutions Identification of target markets and target marketing for the development of medical and health resort tourism Organizing online marketing campaigns Development and implementation of medical tourism promotion strategy 0.057 4 A 0.227 O 007
0.05/ 0.057 4 4 O 3 0.zz/ 0.227 O 17PI
4 5 0.057 0.057 4 0.170 0.227
6 Development and implementation of spa-resort tourism promotion strategy 0.057 4 0.227
7 8 9 Improving statistical recording Improving the conditions of medical institutions Educational-scientific development of the sphere 0.057 4 A 4 0.227 O 007
0.057 0.057 4 0.227
Total 0.511 1.989
Threats
Existence of internationally recognized medical and resort 1 tourism destinations, which are in great demand in the international market
0.057 3 0.170
2 Less developed healthcare system compared to competing countries
3 Lack of investment
4 Underdeveloped infrastructures
5 High prices for air tickets to Armenia
6 Regional tension with neighboring countries
7 Unstable political situation
8 Medical system congestion due to the pandemic
9 Travel restrictions due to the pandemic Total
0.045 4 0.182
0.057 n DAR 4 O 0.227
0.045 0.057 3 3 A 4 0.I36 0.170 n 007
0.057 0.057 2 A 4 0.zzZ 0.114 H 007
0.057 0.057 3 0.zzZ 0.170
0.489 1.625
The total weighted score of opportunities and threats is 3.614. As we see, the EFE and IFE are above average 2.5. Figure 1 shows the IE matrix and the best strategy based on the weighted scores. The obtained score is in the aggressive quadrant (Figure 1).
Conservative Aggressive
Defensive Competitive
IFE score Figure 1. IE strategy space matrix
Source: Based on the research results of the author.
Aggressive quadrant of the SPACE Matrix is an excellent position to use its internal strengths to take advantage of external opportunities, overcome internal weaknesses and avoid external threats.
Placing the same scores in Figure 2, the optimum strategic steps may be obtained.
Total IFE weighted score
I
f Grow and v., build 4 Strong 3.0-4.0 Average 2.0-2.99 Weak 1.0-1.99
High 3.0-1.0 •
Medium 2.0-2,99
Low 1.0-1.99
Hold 'I'd maintain
Harvest
and divest
Figure 2. The Internal-External Matrix
Source: Based on the research results of the author.
The Grow and build strategy signifies intensive and aggressive tactical strategies. This means focusing on market penetration, market development, and product development. It supposes to expand aggressively by capitalizing on strengths. Thus, the best steps for healthcare tourism in Armenia is to develop effective tourism products and make every effort to penetrate into new markets.
Based on the SWOT results, another score may be calculated:
(Strengths + Opportunities) / (Weaknesses + Threats) = = 3.768 / 3.474 * 1.085
This score signifies that sectoral Strengths and Opportunities are about 1.1 times larger than Weaknesses and Threats, which means that there is a lot of work to do to overcome Weaknesses and Threats for healthcare tourism development.
Thus, based on the analysis results, the main steps for the development of medical and spa- resort tourism may be summarized.
Table 6
Necessary measures for the development of medical and spa-resort tourism in the Republic of Armenia37
Basic steps
Improving the
statistical recording and legislation of the healthcare tourism in the RA
Description of events
Develop separate programs for the development of resort areas in Armenia.
Develop spa-resort tourism development program.
Develop medical tourism development program in Armenia.
Improve the statistical recording of the sector, which will allow to find out
which countries medical and sanatorium tourists mostly come from, what
services they use, which is needed for more substantiated, effective
research.
Improve the legislative framework of the sector.
37 Source: Developed by the author as a result of the analysis
Improving the marketing activities of the healthcare tourism in the RA
Increasing the competitiveness of healthcare services and the demand for them
Improving the business and investment environment of medical and spa-resort tourism
Scientific support for the organization of treatment and
tourism development
On a separate page on the official tourism website of the Republic of Armenia to present in detail the resort areas of the Republic of Armenia, their medical resources, existing sanatoriums and the sanatorium services provided by them.
Addition of a separate section on medical tourism on the official tourism website of the Republic of Armenia, with a systematic presentation of services and medical institutions in order to promote them. Creation of a separate online platform in addition to the relevant sections on the official tourism website of the Republic of Armenia, with the presentation of medical and health services, prices, institutions, with the possibility of booking.
Develop and implement advertising programs.
Carry out targeted marketing according to different target markets.
Use a wide range of e-marketing tools using social networks to introduce
Armenia's medical and health services abroad to attract inbound tourists.
Use influencer marketing with the involvement of famous Armenians.
Participate in international tourism exhibitions, present the results of the
country's health and medical tourism.
Develop a brand of the RA resort areas.
Improve the quality of medical services.
Improve the conditions of the RA medical institutions.
Improve the quality of sanatorium services.
Increase the level of service in health resorts.
Apply a policy of price discounts to promote long-term health care to attract different groups of tourists.
Apply a policy of price discounts and competitive pricing to attract medical tourists.
Promote spa-resort rest through social assistance programs, contributing to the solution of the population's health problems. Expand access to health care to the general public through social assistance programs.
Organize various practical events, conferences in hotels and sanatoriums included in resort areas.
Internationally accredit medical institutions of the RA. Take steps to attract investment to develop infrastructures. Encourage private investment by providing tax, credit, and other benefits in order to renovate old sanatoriums, medical facilities, and build new ones.
Establish a mechanism for allocating tourism revenues and investing it in tourism destinations.
Prepare the necessary scientific staff for the development of the field, both in the field of organization of sanatorium treatment and in the sanatorium and medical tourism management and development. Improve experiences organized by educational institutions by cooperating with medical institutions, sanatoriums, providing employment opportunities for students.
Improve the organization of sanatorium treatment, spa-tourism education by studying international experience, developing educational programs in the field, including specialists in the educational process. Increase the scientific and educational level of the employees of the field by conducting professional training courses from time to time. Organize international professional conferences, scientific seminars.
Conclusions. The analysis shows, that healthcare tourism has perspectives of development in Armenia, due to available resources, affordable prices. The main tourists are Armenians from the Diaspora, Russia, also foreigners from different
countries. Tourists mainly come for dental treatment, cosmetic surgery, etc. We have highly qualified doctors, which is also another important factor for choosing medical tourism destination. Besides medical tourism, wellness tourism also attracts tourists to the resort zones of Armenia, which have all the necessary curable resources.
However, the SWOT analysis showed some issues connected with the lack of statistical data, the inefficiency of marketing performance, competitiveness level of medical services, lack of investments, low level of educational-scientific activity of the sphere. Based on the scores of SWOT analysis the best strategy for healthcare tourism was defined, which is aggressive strategy with 'grow and build' strategical steps.
In order to overcome the main problems, measures should be taken in various directions:
• Improving the statistical recording and legislation of healthcare tourism,
• Improving the marketing activities of healthcare tourism,
• Increasing the competitiveness of medical services and the demand for them,
• Improving the business and investment environment of healthcare tourism,
• Scientific support for the organization of treatment and tourism development.
The paper also proposes some measures by these directions. The developed directions and steps may be basis for creating strategical plans for the sphere promotion.
The implementation of the above-mentioned steps will contribute to the development of the the RA resort infrastructure, the increase of the quality of medical and wellness services, the competitiveness of the resort complex, the development of spa-resort tourism, the improvement of medical services and the development of medical tourism.
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DOI: 10.52174/1829-0280_2021_5_107
ГАЯНЕ ТОВМАСЯН
Старший исследователь исследовательского центра «Амберд» АГЭУ,
преподаватель Армянского государственного экономического университета и
Академии государственного управления РА, кандидат экономических наук, доцент
Здравоохранительный туризм в Армении: возможности и перспективы развития.- Люди начали путешествовать в медицинских целях с древнейших времен. В настоящее время здравоохранительный туризм - одна из быстроразви-вающихся отраслей в мире. В Армении также есть возможности для развития здравоохранительного туризма. В Армению в основном приезжают для лечения зубов, косметической хирургии и т.д. В статье представлены некоторые международные тенденции развития медицинского туризма, проанализированы ресурсы медицинского и оздоровительного туризма, а также представлено современное состояние последних. С помощью оценок SWOT-анализа была определена лучшая стратегия развития здравоохранительного туризма - агрессивная стратегия. По результатам анализа были предложены шаги в следующих направлениях: усовершенствование статистического учета и законодательства в сфере здравоохранительного туризма, улучшение маркетинговой деятельности в этой сфере, повышение конкурентоспособности медицинских услуг и спроса на них, улучшение деловой и инвестиционной среды здравоохранительного туризма, а также научная поддержка организации лечения и развития здравоохранительного туризма. Результаты исследования могут быть полезны государственным ведомствам, частному сектору и т.д. для разработки и реализации планов по развитию здравоохранительного туризма.
Ключевые слова: здравоохранительный туризм, здоровье, лечение, курорт, SWOT, стратегия, Республика Армения. JEL: L83, I15
DOI: 10.52174/1829-0280_2021_5_107
