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24Перспективы роста медицинского туризма в Армении
Medical Tourism Growth Perspectives in Armenia
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Арутюнян Владимир Липаритович
директор Института экономики им. М. Котаняна Национальной академии наук Республики Армения (НАН РА) (г. Ереван), доктор экономических наук, профессор, член-корреспондент НАН РА
0015, Республика Армения, г. Ереван, ул. Григора Лусаворича, д. 15 Vladimir L. Arutyunyan
Institute of Economics named after M. Kotanyan of the National Academy of Sciences of Armenia
Grigora Lusavoricha Str. 15, Yerevan, Republic of Armenia, 0015
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Дохолян Сергей Владимирович
главный научный сотрудник Института социально-экономических исследований Дагестанского научного центра РАН (г. Махачкала), доктор экономических наук, профессор
367030, Республика Дагестан, г. Махачкала, ул. Ярагского, д. 75 Sergey V. Dokholyan
Institute of Social and Economic Research Dagestan Scientific Center, Russian Academy of Sciences
Yаragskogo Str. 75, Makhachkala, Russian Federation, 367030
В исследовании рассматриваются актуальные вопросы развития медицинского туризма в Армении.
Цель. Исследование направлено на выявление перспектив, которые определят путь развития медицинского туризма в Армении в среднесрочной перспективе.
Задачи. Определить страны-источники, те туристические продукты, которые были и могут быть привлекательными для иностранных туристов, ключевые факторы успеха, чтобы предложить возможный сценарий развития медицинского туризма, ожидаемый в среднесрочной перспективе. Методология. Исследование построено на основе общих научных методов познания, включая аналитический, методологический и элементы прогнозирования, структурного и сравнительного анализа. С помощью аналитического метода исследования, основываясь на обзоре литературы и анализе деятельности ниши медицинского туризма в Армении за период 2006-2017 гг., был выявлен возможный путь развития медицинского туризма. Результаты. С 2013 г. число пациентов, привлеченных Арменией, начало расти, что привело к увеличению поступлений от лечебно-оздоровительного туризма, которые в 2017 г. достигли самого высокого уровня с 2006 г. и выросли более чем в 8 раз за тот же период. Казахстан стал ведущей страной-источником по количеству пациентов, перенесших косметические операции в Армении, за ним следуют армяне и россияне из России (90% российского происхождения). Армянская диаспора также предпочитала Армению и
приезжала на пластические операции. Стоматологические услуги тоже являлись драйвером роста этой ниши. Ценовая конкурентоспособность, наличие профессиональных врачей и медицинского оборудования сыграли важную роль в привлечении медицинских туристов в Армению.
Выводы. В среднесрочной перспективе Армения, скорее всего, будет опираться как на казахстанских, так и на российских медицинских туристов и армян из диаспоры, как из развитых стран, так и из СНГ (включая Грузию). Ценовая конкурентоспособность будет являться решающим фактором. Сарафанное радио, личные контакты, социальные сети в сочетании с положительными статьями в журналах медицинского туризма и на вебсайтах других специализированных консалтинговых компаний, которые рекомендовали бы Армению в качестве благоприятной страны для медицинского туризма, будут являться эффективными каналами распространения для привлечения большего количества пациентов. Для удовлетворения растущего спроса потребуются новые медицинские центры. Государственная поддержка туроператорам, продвигающим медицинский туризм в Армению, может быть ключевой, наряду с господдержкой и стимулами для инвесторов, для постройки клиник и закупки оборудования. Следовательно, расходы иностранцев на лечебно-оздоровительный туризм могут вырасти более чем в 2 раза и достигнуть 250 млн долл. США в 2022 г. Полученные результаты могут быть использованы Государственным комитетом по туризму в подготовке будущих
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планов действий, разработке стратегий по развитию ниши медицинского туризма и т. д. Ключевые слова: медицинский туризм; медицинские услуги; конкурентоспособная стоимость; страна-источник; пункт назначения; Армения.
Для цитирования: Арутюнян В. Л., Дохо-лян С. В. Перспективы роста медицинского туризма в Армении // Экономика и управление. 2018. № 11 (157). С. 19-28.
The presented study examines the relevant problems of development of the pharmaceutical industry in Armenia.
Aim. The presented study aims to determine the prospects of development of medical tourism in Armenia in the medium term. Tasks. The authors identify the source countries, i.e. tourism products, which have been or can be attractive to foreign tourists, and key factors of success to propose a possible scenario for the development of medical tourism in the medium term.
Methods. This study uses general scientific methods of cognition, including analytical and methodological approaches, and elements of forecasting, structural and comparative analysis. The analytical research method, review of literature, and analysis of medical tourism in Armenia in 2006-2017 are used to determine the potential development path for medical tourism.
Results. Since 2013, the number of patients attracted to Armenia has grown, leading to an increase in the proceeds from medical and health tourism. In 2017, these have reached its highest level since 2006, increasing eightfold over the same period. Kazakhstan has become the leading source country in terms of the number of patients who have undergone cosmetic surgery in Armenia, closely followed by Armenians and Russians from Russia (90% of Russian origin). The Armenian diaspora also prefers Armenia for plastic surgery. Dental services are another growth factor in this sector. Competitive prices, professional doctors and medical equipment play a vital role in attracting medical tourists to Armenia. Conclusions. In the medium term, Armenia is likely to rely on medical tourists from both Kazakhstan and Russia as well as Armenians from developed countries and the CIS (including Georgia). Price competitiveness will be the decisive factor. Word of mouth, personal contacts, and social networks, combined with positive articles in medical tourism journals and on websites of specialized consulting companies advertising Armenia as a favorable destination for medical tourism, will serve as efficient distribution channels capable of attracting more patients. New medical centers will be required to meet the increasing demand. Government support for the tour operators that promote medical tourism in Armenia may be crucial, along with government support and incentives for investors to build clinics and buy equipment. As a result, the expenses of foreigners on medical and health tourism may
increase more than twofold, reaching 250 million US dollars by 2022. The obtained results can be used by the State Committee for Tourism in the preparation of future plans and strategies for the development of medical tourism, etc.
Keywords: medical tourism; medical services; competitive price; source country; destination; Armenia.
Citation: Arutyunyan V. L., Dokholyan S. V. Perspektivy rosta meditsinskogo turizma v Armenii [Medical Tourism Growth Perspectives in Armenia]. Ekonomika i Upravlenie, 2018, no. 11 (157), pp. 19-28.
Introduction
«A sector that has immediate linkages with international trade, finance, and mobility of people, tourism is a crucial area where globalization is nurtured and strengthened» [1, p. 10].
With further developments of globalization, increase in mobility travel and tourism sector is expected to grow, and over the period 2018-2028 would reach 12,450.1 billion US dollars in 2028 (or 11.7% of the world GDP), while compared to 8,272.3 billion US dollars (or 10.4% of the world GDP) in 2017, associated with the growth in visitor exports that would amount to 2,311.4 billion US dollars in 2028 compared with 1,494.2 billion US dollars in 2017 [2]. Hence, each nation has good chances to attract more and more international tourists, thus ensuring receipt of foreign exchange that would enable the nation to support the domestic tourism industry and build an attractive tourism specific infrastructure and other facilities to further promote the country as a tourism destination. However, the question is which niche each nation can appeal to attract more international visitors and which destinations it to could rely on.
Armenia is an interesting case that managed to report a strong growth in terms of both international tourist arrivals and tourism receipts (excluding transportation costs) over the period 2006-2017 (see table 1). In the same period, the number of international tourists was growing at a compound annual growth rate (CAGR) of 13.2% ([3], authors' own calculations), while the travel expenditure reported an annual growth rate of 10.6% (CAGR) ([4] authors' own calculations). An increase in health-related tourist receipts was reported over the same period, as well. International tourist spending on medical treatment and/or health services in Armenia were growing at a compound annual growth rate of 21.7% ([Ibid.]; authors' own calculations) in the period 2006-2017. This means that medical treatment in Armenia has started to be preferred by a growing number of medical tourists com-
Table 1 g
International Tourist Arrivals and Tourism Receipts in the period 2006-2017 |
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
The outbonds that are tourists on the WTO methodology (thousand people) 382.2 510.3 558.4 586.8 729.3 832.7 963.0 1,082.0 1,203.7 1,192.1 1,259.7 1,494.8
Travel expenditure (million US dollars) 369.84 483.91 517.57 530.00 645.71 722.40 817.45 880.39 965.84 935.82 967.70 1,120.17
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Medical Tourist Destination Region
Asia/Middle East The Americas Europe Africa Other
China Argentina Belgium South Africa Australia
India Barbados Czech Republic Tunisia New Zealand
Israel Brazil Germany
Jordan Canada Hungary
Malaysia Colombia Italy
Singapore Costa Rica Latvia
South Korea Cuba Lithuania
Philippines Ecuador Poland
Thailand Jamaica Portugal
Taiwan Mexico Romania
Turkey United States Russia
United Arab Emirates Spain
Source: [7, p. 30].
ing to Armenia to be provided with respective medical services.
Hence, the purpose of the article is to identify the potential source countries, tourism products and to build the possible medical tourism growth scenario that could be expected in the medium term.
Methodology
Based on the literature review, and the analysis of the performance of the medical tourism niche in Armenia over the period 2006-2017 to build the possible medical tourism growth scenario that could be envisaged in the medium term.
Literature Review
Beladi et al. by estimating the impact of medical tourism revenue on the real output growth rate for OECD and non-OECD country groups found that medical tourism revenue significantly affects the output growth in the case of nonOECD countries [5]. Hence, an average nonOECD country could benefit from positive gains offered by the medical tourism revenue in the destination country and become more involved in this activity.
Based on data on health-related travel of a sample of countries (that includes Armenia as well) from 2003 to 2009, Loh found that the «import and export of health tourism rose
among countries with a high volume of such activities (accounting for the upper 40% of the countries), ... while countries with a low volume of import or export, or the lower 60% of countries conditional on income level, saw little expansion» [6, p. 759, 763]. Thus, there is a possibility of attracting more medical treatment seeking tourists over the medium term, with the increase of «such activity» in Armenia.
Tae Gyu Koin, by providing a detailed description of Medical Tourism System Model, offered the list of Medical Tourist Destination Regions that attract medical tourists worldwide, by completing the list (see table 2) [7, p. 30] compiled by Horowitz et al. [8, p. 34]. And based on the literature review (by referring to Gahlinger [9], Marsek and Sharpe [10, p. 39-76], Smith and Puczko [11, p. 7]) Tae Gyu Koin [7, p. 32] presented the main medical tourism products (see table 3).
According to Alvarez et al., regional pattern and or/proximity prevailed in choosing a destination to be provided with medical services [12, p. 210]. Patients from the US and Canada opt for Brazil and Costa Rica; Western Europeans seek for medical treatment in Eastern Europe; the patients from Pakistan and Gulf countries go to South and South East Asia, namely India and Thailand [Ibid.]. According to Alvarez et al., the choice of a destination depends on the specialization of a country in a particular type of medical tourism product along with «re-
Main Medical Tourism Products
Major Surgeries Orthopedic surgeries; Spinal procedures; Limited cardiac procedures: angioplasty, cardiac diagnostic procedures; Gynecological surgeries: partial hysterectomy, total hysterectomy, radical; Hysterectomy, bilateral salpingo oophorectomy; General surgeries: vascular, stomach and bowel, kidney and urinary, gallbladder removal, Hernia repair, cataract surgery, LASIK surgery, hemorrhoid removal, Endo laser vein surgery; Other medical procedures: bariatric surgery, fertility treatment, Oncology, transplants, and etc.
Minor Surgeries Dental procedures: dental work, cosmetic dentistry, crowns, bonding, veneers, whitening, bridges, bone grafts, root canals, tooth extractions; Eye, ear, nose, and throat treatments
Cosmetic/Plastic Surgeries Facial cosmetic surgery; Body contouring
Diagnostic Services
Alternative Therapy Treatments Chinese medicine, herbal treatments, and etc.
Wellbeing/Lifestyle Remodeling Services Spa therapy, thermal therapy (mineral springs, balneo therapy), thermo therapy, aroma therapy, and etc.
Source: [9; 10, p. 39-76; 11, p. 7].
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gional proximity» [Ibid.]: Thailand and India are preferred for orthopaedic and cardiac surgery, while the Eastern European nations serve as a destination for the patients to opt for dental services [13]. Meanwhile, according to Tae Gyu Koin [7, p. 39], the services required for different medical tourist types will vary across main medical tourism products [14, p. 35]. In the case of major surgeries the «medical staff, equipment and facilities, and recovery options» could be prioritized, while in the case of the well-being products «high level of accommodation and food, and tourist facilities and services» would be emphasized.
One of the papers addressing all possible factors contributing to the choice of a specific destination is the article by Esiyok et al. [15, p. 66-67]. Based on the literature review, the authors provide a detailed list of factors that determine and explain the choice of a destination country by international tourists seeking medical treatment abroad, and among them are the followings [Ibid., p. 66]:
• issues with respect to difficulties in getting health care owing to relatively high cost in the countries of origin, exclusion of users with low income by the insurance, the duration of the waiting time to receive respective health care services; and relatively low quality of services [16-18];
• affordable airfare and favorable foreign exchange rates [16];
• the quality of health care services in the country of origin while compared to the quality of respective services in the destination country [19];
• hospital accreditation [20], geographical distance [21], familiarity with the culture and/ or cultural proximity [19].
Among the factors singled out by Esiyok et al. [15, p. 67] that contribute to the choice of
Diasporans in favor of own homeland as a destination to receive medical services are the fol-lowings:
• «Social and historical connectedness» [22];
• Communication in native tongue [23; 24];
• Personal connections and ties [25].
And based on the empirical results, Esiyok et al. state that the importance of cultural distance and/or proximity needs to be incorporated in designing marketing strategies with respect to medical tourism [15, p. 72].
One of the drivers of the health tourism would be the aging population since according to Csirmaz and Peto «ageing but at the same time active age groups» in the North America, Scandinavia, and Western Europe and who long for higher standards of quality of life could be considered as a group with «a huge potential for wellness tourism» [26, p. 755]. By referring to Kiss and Torok [27] and Ratz [28], Csirmaz and Peto state that wellness-fitness services that became popular in the 1990s along with traditional health and thermal tourism would report more dynamic growth than that the health tourism is expected to grow at [26, p. 757].
Caballero Danell & Mugomba provide with «three identified channel distribution modes that link the consumer to the destination; operators, representatives within targeted consumer markets that are also referred to as intermediaries and word of mouth» [29, p. 35], while Heung et al. have developed the Supply and Demand Model of Medical Tourism conceptual model, to pinpoint the needs of the tourist in choosing a destination, and etc. [30, p. 244, 249].
Results/Analysis
Over the period 2006-2017, among the holiday niches that Armenia tried to be attractive for, Visiting Friends and Relatives (VFR) prevailed
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120 110 100 90 80 70 60 50 40 30 20 10
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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year
Figure 1. Health-related tourist receipts from 2006 to 2017 (million US dollars)
S o u r c e: [4].
accounting for 51.2% of the purpose of the trip to Armenia according to the respondents of Armenian International Visitor Survey in 2013 [31, p. 25] while compared to 44.8% in the period 2006-2007 [32, p. 11]. This high percentage of VFR visits among international arrivals was attributed to the visits of Diasporan Armenians and/or «visitors with Armenian roots». Among the tourists with Armenian roots the two major purposes of visiting Armenia were reported the followings: VFR (62%) followed by Health and/ or medical tourism (about 12%) [31, p. 27]. In the case of medical tourists, Diasporans from Georgia were the main group of medical tourists, followed by patients from Russia of Armenian origin, the United States and Canada. Since 2013, the number of patients attracted by Armenia has started growing, thus resulting in an increase in health-related tourism receipts that reported the highest level in 2017 since 2006. In 2017, the numbers of international tourists that arrived in Armenia to receive medical treatment or to be provided with health services reported an increase of about 45% (y./y.) while compared to 2016 [33, p. 96]. The international tourist spending on health-related travel to Armenia reported more than 8-fold increase over the pe-
riod 2006-2017 (see figure 1), and in 2017, the increase amounted to 27.2% (y./y.).
The increase in the number of medical tourists to Armenia over the 5-year period was driven by the growth in the number of patients from other countries as well. According to the International Medical Travel Journal (2017), Kazakhstan emerged as a leading source country in terms of the number of patients undergoing surgeries in Armenia, followed by Armenians and Russians from Russia with 90% of Russian origin, while in case of the medical tourists from Australia and Netherland Diasporans prevailed [34].
Although the number of patients from EU countries is small, however, «cosmetic surgery tourists have arrived from France and the UK» [Ibid.]. Cosmetic surgery contributes to the growth of medical tourism, thus attracting Kazakhstani and Russian patients [Ibid.]. According to the Chairman of the Armenian Association of Plastic Surgeons, Armen Hovhan-nisyan, the quality of surgeries nearly equals to that of American or European medical centers, however, «it is several times more affordable», thus explaining the reason why Diaspora Armenians prefer Armenia, since they «mainly arrive in Armenia for plastic surgery» [35].
Prices for Medical Services in Various Destinations
Service/Country Germany Thailand Israel Belgium Hungary Armenia
Face Lift 2000 1200 1500 1800 2500 1200
Breast Implant 3000 2000 2500 3000 3000 2000
Rhinoplasty 5000 2000 3000 6500 4000 1500
Breast reduction 5500 2500 3500 6000 4500 2200
Cardiology diagnosis 600 200 300 500 450 150
Dental Implant 1000 700 700 1000 600 400
Eye laser treatment 5000 1500 2500 4500 4500 1000
Body Laser hair removal 1000 600 750 1000 1000 600
Artificial Insemination 2950 2300 2500 3000 2500 2000
2 Source: [39].
§ However, the local surgeries need government
v assistance in marketing the country as a destination [34], since each surgeon attempts to increase the number of patients via personal connections [35]. The chairman of the Armenian Association of plastic Surgeons stated that «I had several meetings with a number of organizations that conduct a marketing to understand in what directions the healthcare tourism can develop in Armenia» [Ibid.].
Most of the renowned clinics that are located in Yerevan, the capital of Armenia, have a potential «for handling up to 500 customers in a month» [36]. A tri-lingual (Armenian, English, Russian), the mobile app has been developed by iMed, a domestic company to link possible patients with surgeons, to examine the new look upon surgery, and etc. [34].
Dr. Prem, medical tourism consultant [36] provides several reasons explaining why Armenia has transformed itself into «a global hotspot for cosmetic surgery» and among them are the followings:
• Highly professional surgeons and doctors;
• Availability of world class surgical equipment;
• Geographical location;
• Tourist safety;
• Amenities and other facilities.
Apart from resort tourism that could be a thriving tourism niche, since there are about 400 mineral sources in the territory of Armenia that have enabled the county to build high-standard resorts and are currently being built to provide a wide range of services with «competitive price policy», surgery tourism and dental tourism are also reporting a growth due to «flexible and affordable price systems» that attracted international patients [37]. According to InterMedLine interesting options and solutions could be proposed for plastic surgeries and dental care, and more complex cardiac surgeries as well [38]. The drivers that attract patients from abroad are the price savings (up to 70%) comparing to prices in the United States and Western Europe [Ibid.]. Sardarian [39] provides
the comparison of prices for various services in different destinations enlisted in table 2 (including Armenia) that attract overseas patients (see table 4).
Armenia is considered the most cost-competitive destination to opt for by patients from source countries. The cost for Rhinoplasty is considerably low in Armenia than in European counterparts and lower than in Thailand. While competing with Thailand, two factors will be crucial: marketing campaign and word of mouth to raise brand and/or consumer awareness; and airfare and lack of direct flights from major EU destinations. Armenia has direct flights to some major destinations: Berlin, Paris, Vienna, Warsaw, Moscow, Saint Petersburg, Tel Aviv, Doha, Dubai, Beirut, Kiev, Tbilisi, Aktau, (Kazakhstan), Beirut and etc. [40]. Hence with the growth of a number of both medical and non-medical tourists, Armenia could attract other airlines in the medium term and even low-cost airlines over the long-run.
According to Medical Tourism Magazine, «Armenia is slowly becoming a popular dental tourism destination for patients from Europe and as far away as the United States» [41]. And according to the founder of Dental Tourism Armenia, Dr. David Hovhannisyan, «services at packaged concierge rates» could be affordable for the patients with limited and/or no dental insurance coverage and would be rendered and provided by doctors and specialist who use advanced western technologies [Ibid.].
Armenian leading healthcare experts, tourism professionals and educators in Armenia have decided to partner with the Medical Tourism Association® «to put some teeth in procedures and treatment opportunities that they believe will attract more patients», hence resulting in a memorandum of understanding between the Medical Tourism Association® and MTA Armenia to establish a regional MTA chapter that will be in charge of designing healthcare and hospitality training and certification programs; providing higher-quality services to patients,
namely «health and wellness seekers», while strengthening the image of Armenia as a medical tourism destination around the globe [Ibid.].
According to MIR 24 TV channel, every tenth tourist that visits Armenia comes to improve their health, since the quality of health services meets the international standards. According to one orthodontist, Haykush Aleksanyan, about 40% of their patients were foreigners, mostly from Georgia, Russia and china. Word of mouth, social networks (via pictures posted on personal pages) play a key role in spreading the results reported by Armenian plastic surgeons. Many clinics have started organizing special tours that include accommodation and airline ticket in addition to health and/or medical services and are planning to make the packaged tours by adding excursions in Armenia, and the Ministry of Health of Armenia is drafting a paper that would allow promoting medical tourism [42].
The growing role of medical tourism and the potential of thereof enabled this niche tourism to appear among those ones that State committee for Tourism of the Ministry of Economic Development and Investment of Armenia is planning to develop strategies to package and promote products for and develop spa and health tourism niches [43].
The possible scenario that could be expected in the medium term would be the following:
• comparatively low price for cosmetic and/or plastic surgeries and dental services coupled with the availability of professional doctors and world-class medical equipment would continue attracting more and more patients from mainly cIS countries and Diaspora both from the cIS and developed countries as well;
• Armenia builds new clinics and/or hospitals equipped with advanced, world class-medical technology to meet the growing demand of Kazakhstani, Russian, and Diaspora tourists that would prefer Armenia to other medical tourism destinations. The government support to the industry could be both in the form of tax incentives or exemptions for newly built hospital and/or the ones that are under the construction and for the purchase of world-class medical equipment; and assistance to a marketing campaign to attract new tourists for both new and existing medical centers;
• Word of mouth, social media, personal contacts, positive articles in medical tourism specialized journals and/or consulting company websites would drive the growth. Besides those Armenian tour operators that offer medical tourism packages (Doctortour. am, Barev Armenia, ANRIVA-TOUR, Sputnik, TOUR&CURE [44-48]) to patients, new operators would start offering such packages. The tour operators could partner with source
country outbound tour operators to attract ^ more patients seeking treatment abroad. State | support to specialized tour operators would ° drive the growth of this market niche as well. ° With the state support channeled to the development of this niche, Armenia could attract s patients who need cardiac and other types of ^ surgeries over the long-run. The channels of ^ distribution that would ensure the influx of ^ patients in need for cardiac and other types s of surgeries would be the word of mouth and ^ personal contacts along with positive articles ° in various Medical Tourism journals abroad,
and etc. 2
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Practical Implication ^
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The findings could be used by the State Tourism Committee in drafting future action plans, elaborating strategies to ensure medical tourism niche growth, and etc.
Conclusion
Overall, Armenia is emerging as a cosmetic and/ or plastic surgery, and dental services' spot for both Diasporans and Kazakhstani and Russian medical tourists. In the medium term, Armenia would likely rely on both Diaspora Armenians from both developed countries and CIS (including Georgia). The tourism products that would contribute to the growth of the medical tourism niche will still remain cosmetic and/ or plastic surgeries and dental services. Price competitiveness would be a crucial factor that would drive the growth of this holiday niche coupled with the high standards of health services, and safety concerns. Word of mouth, personal contacts, and social media were the most effective distribution channels that helped Armenian surgeons to attract patients. These distribution channels would likely be the most effective ones coupled with positive articles in medical tourism magazines or posted on specialized consultancy websites that would recommend Armenia as a favorable medical tourism destination, and a growing number of partnerships with overseas outbound tour operators by local tour operators. Availability of modern equipment and professionalism of surgeons and/or doctors were the key enabling factors that will continue to be so in the medium term as well. The Government support to new investors, in the forms of tax incentives who want to build new clinics and/or hospitals, or purchase advanced, world-class medical equipment would be a strong incentive to attract new investments, both local and foreign ones. Special measures need to be designed for hospitals that attempt to promote their services abroad, by partially
g or fully covering the marketing costs. Support | to tour operators promoting medical tourism to ° Armenia could be vital. Hence, health-related ° tourism receipts could be more than doubled
and reach 250 million USD in 2022.
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m
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