Baltic Journal of Economic Studies 23 Vol. 9 No. 5, 2023 This is an Open Access article, distributed under the terms of the Creative Commons Attribution CC BY 4.0 1 Klaipeda University, Lithuania (corresponding author) E-mail: juliuss.ramanauskas@gmail.com ORCID: https://orcid.org/0000-0001-6250-3103 2 Lithuania Business University of Applied Sciences; Klaipėda University, Lithuania E-mail: sarunas.banevicius@ltvk.lt ORCID: https://orcid.org/0000-0002-5942-9966 3 Lithuania Business College, Lithuania E-mail: jevgenija.jerochina@ltvk.lt DOI: https://doi.org/10.30525/2256-0742/2023-9-5-23-32 ASPECTS OF THE SOCIO-ECONOMIC IMPACT OF HEALTH TOURISM Julius Ramanauskas1, Šarūnas Banevičius2, Jevgenija Jerochina-Labanauskienė3 Abstract. Tourism is considered as a powerful life force for economic and social development. The tourism sector stimulates economic growth both nationally and internationally, increasing employment and investment, with the export of services developing in both quantitative and qualitative terms. Tourism contributes to the preservation of cultural and natural heritage, it guarantees income which could be used to finance cultural heritage objects and infrastructures, promoting the overall perception of European identity and citizenship based on diversity and exceptionality (European Tourism Manifesto, 2022). In 2021, Lithuania Travel, a public enterprise, carried out research on the development of the tourism sector with the analysis of research findings provided by the expert group of the World Tourism Organisation (WTO) and the European Travel Commission (ETC). According to the research, the period of crisis caused by the COVID-19 pandemic, as well as the severe restrictions applied to the tourism sector in all countries, which not only had short-term negative effects, but also changed travel traditions and habits (increased demand for nature and domestic tourism, health, hygienic conditions and safety considered as the most important criterion when choosing a travel destination), is also relevant as Lithuania needs to maximise its potential by creating an image of a safe country with high standards of hygiene. According to the above-mentioned research, the integration of innovations and technological novelties in the tourism sector was also emphasised. In the course of the development of the tourism industry, of which the segment of health tourism is a part, with the ambition not only to reach the quantitative rates of 2019, but even to exceed them, it is reasonable to assess the socio-economic impact. The aim of this article is – to present aspects of socio-economic impact of health tourism on sending and receiving countries. During the systematic review of the research literature, the search for research articles was carried out in the following databases: Cambridge Journals Online; EBSCO; Emerald Publishing; SAGE Journals Online; Science direct; Tylor&Francis etc. The research articles included in the systemic research review cover the period from 1999 to 2023. The methods of comparative analysis, synthesis, graphical presentation and generalisation were used to present the research results. The study assessed the socio-economic impact of health tourism in two areas: positive and negative impact on the countries that send and receive tourists. The analysis of the research literature carried out has shown that if the appropriate regulatory mechanism of health services is not ensured, as well as the appropriate and fair distribution of income from health tourism activities, it may be difficult for low-income social groups to receive timely health services. Therefore, during the development of the health tourism industry, special attention should be paid to ensuring equal access to health services for all social groups, as well as to the training of competent professionals working in health tourism organisations. Key words: health tourism, social-economic impact, health tourism structure. JEL Classification: H8, I11, L83, M10, M21 1. Introduction Currently, tourism is facing challenges due to its vulnerability to unprecedented situations and recessions such as COVID-19. Despite the challenges of the external environment, the tourism industry has, in its own way, developed resilience to cope with economic, social, health and environmental risks (i.e., natural disasters, infectious diseases, etc.). Nevertheless, Baltic Journal of Economic Studies 24 Vol. 9 No. 5, 2023 COVID-19 has brought an unprecedented recession to the tourism industry. Before COVID-19, the tourism industry had shown significant economic impact in various regions and countries, and in developing countries it was considered as one of the measures for poverty reduction. In such a situation, the segment of health tourism, as a combination of healthcare and tourism services, could be considered as a solution that helps to train resistance to the current and future recession, as well as to increase both the economic and social impact of tourism. One of the reasons explaining the positive change is related to the integration/merger of a large number of subjects included in health tourism, while the convergence could have a broad and positive economic and social impact on both the sending and receiving countries, causing a spill-over effect on the surrounding regions (at micro- and macro-levels). Promoting the sustainability of tourism is expected to become one of the biggest challenges for the travel industry today and in the near future, with the application of a wide range of new means as well as rapidly developing technologies. Tourism enables people to choose new destinations; however, as emphasised by Hodžić and Paleka (2018), Kim et al. (2019), Dragičević and Paleka (2019), Vega-Vazquez et al. (2020), Szromek et al. (2023) and others, when making the decision to travel, a healthy environment becomes even more important than the very new destination. Contemporary tourism combines travel purposes with physical activity and relaxation, which not only successfully restore the human body and mind, but also prevent health problems. Research problem. How to assess the socio-economic impact of health tourism? The object of the study is the socio-economic impact in the field of health tourism. The goal of the study is to assess the socio-economic impact of health tourism in two areas: positive and negative impact on the countries that send and receive tourists. Objectives: to describe the concept of health tourism; to evaluate aspects of the socio-economic impact of health tourism. Research methodology: a systematic and comparative review of scientific literature is used to describe the concept of "health tourism". For the theoretical assessment of the socio-economic impact of health tourism on host and sending countries, the methods of synthesis and generalisation, as well as graphical representation are used. 2. Health Tourism Concept 2011/24/ES Directive was adopted by the European Commission with the aim of providing European Union (EU) citizens with equal opportunities to receive healthcare services (screening, diagnosis, intervention and other treatment, regardless of financial means, gender or nationality, according to specific needs) in other countries. The latter facilitates the process of receiving treatment for ES citizens in another ES member state and guarantees at least partial reimbursement of the costs in one's own country (European Commission, 2015b). Nevertheless, the above-mentioned Directive emphasises that Member States remain obliged to provide high quality healthcare services on their own territory, with healthcare services being provided according to their own quality and safety standards. The efficiency of the health system is very important in order to achieve the maximum that can be expected given the level of resources available. Countries need to assess the situation of their health systems in order to manage the arrival of non-resident patients seeking treatment. There is a need for a clear evaluation system that defines the objectives of the health system and against which the results of performance can be assessed. The purpose of international healthcare, including health tourism, is to facilitate treatment abroad; for temporary visitors, e.g., health tourists/patients, to receive the most affordable and appropriate care. Recent studies (Faisal and Dhusia, 2020; Szromek et al., 2023) have shown the increase in healthcare expenditure, which currently averages around 9% of GDP in OECD countries, and the need to address the problems of inequality and inefficiency in healthcare systems. The need to establish an appropriate balance between spending on disease prevention and treatment is also highlighted (UNWTO, 2018). Wong and Hazley (2020), Abd Rashid et al. (2020) state that although the roots of the terms health tourism and medical tourism have been around since the 17th century, it is important to first define the meaning of "health" in order to understand these concepts. According to Benhacine et al. (2008) and UNWTO (2018), health is "not only the absence of disease and malaise, but the state of complete physical, mental and social well-being". This definition fits the general character of the health tourism market, which includes not only the elements of recovery from illness, but also the whole range from illness to health and wellness, from curative to preventive healthcare services (Hall, 2011). According to Ormond and Lunt (2019), international medical travel is the temporary mobility of a patient across national borders with the aim of solving one's health problems abroad, which could not be solved in the countries where one lives. Although health tourism is defined as the use of health services during the entire time spent away from home or one's home country, it has been pointed out that this period should be longer than 24 hours (Baukutė, 2012). Baltic Journal of Economic Studies 25 Vol. 9 No. 5, 2023 It should be acknowledged that the term health tourism is still used very loosely and unsystematically in contemporary literature (Cohen, 2008; Fetscherin and Stephano, 2016; Padilla-Melendez and Del- Aguila-Obra, 2016). For these purposes, the content of the concept of health tourism needs to be specified (Harasim, 2014): – Systematic statistics. It is impossible to assess the impact of tourism on the economy without understanding the types of activities that make up tourism in general, as well as the health and wellness tourism section; – Scientific research. For a thorough study of health tourism, it is important to know what this term means and what aspects of life are included in it (variety of services, etc.); – Improvement of administrative and legislative activities in the field of tourism (including health tourism); – Economic development. Health tourism has a multiplier effect and can generate both direct and indirect income, which is subsequently redistributed to finance and develop other economic activities. According to the Global Spa Summit (2011), the terms health tourism and wellness tourism have been interpreted inconsistently around the world, with the chaos that the latter has caused for organisations at the policy, delivery and imple- mentation levels, as well as for health tourists/ patients. Thus, it is useful to define and differentiate these concepts. By analysing the concepts of health tourism chronologically, the tendency is noted that both the types of health tourism and the concepts coincide with the different activities being integrated. Detailing the variety of definitions of the concept of "health tourism", it is possible to identify its main characteristics: healthcare facilities, health promotion and wellness services; improvement, strengthening, restoration of health – the main motives for travel; travelling outside one's own place of residence (nationally or internationally) for the purpose of obtaining professional medical care; a general term for the following sub-sectors: SPA, wellness and medical tourism; medical services that include diagnosis, treatment, rehabilitation and prevention of diseases. The concept of health tourism could be defined as Table 1 Diversity of definitions in health tourism concepts AUTHOR, YEAR CONCEPTS HEALTH TOURISM IUTO, 1973 The provision of health promotion services by healthcare organisations using natural resources, mineral water, and climate in particular. Hall, 1992,2003; Willson et al., 2018 Health tourism has three elements: 1) travel away from home, 2) health as the main reason for travel, and 3) leisure environment. The commercial phenomenon of industrial society associated with a person travelling away from home for the purpose of obtaining benefits to maintain or improve health, and the provision and promotion of facilities and destinations designed to provide such benefits. Goodrich, 1994; Fuchs and Reichel, 2010 [...] The attempt by a tourist object (i.e., a hotel) or destination (i.e., Baden-Baden) to attract tourists by consciously promoting its health services and technologies, in addition to its general facilities. Hofer et al, 2012; Tourism related to travel to health promotion and wellness centres or resorts with the main aim of improving the physical condition of the traveller through a combination of physical exercise and treatment regimes, nutritional control and medical services. Carrera and Bridges, 2006 Organised travel beyond the boundaries of one's own environment with the aim of maintaining, strengthening or restoring a person's state of mind and body. Bialk-Wolf, 2010 Voluntary trip of a person outside their own country to receive professional medical care, usually surgical or odontological. Smith and Puczko, 2009; Ulaş and Anadol, 2016 Travel to destinations where medical treatment, such as surgery or other specialist procedures, is provided. An umbrella term for other sub-sectors such as SPA, wellness and medical tourism. Altin et al., 2012 ; Mainil et al., 2017 Moving people from their places of residence to other places for the purpose of treatment. Health tourism involves medical tourism, thermal tourism, SPA, wellness, and the tourism of elderly people. Zsarnóczky, 2017 This concept includes medical, preventive and recreational tourism, where the main source of motivation is the improvement and/or maintenance of health. Junio et al., 2017 This is a broad term that encompasses travel with the aim of undergoing various types of treatment to improve physical and mental wellbeing, ranging from medical interventions (optional or compulsory), to traditional and alternative treatments, to holistic medicine offered by SPAs and wellness centres. Dragičević and Paleka, 2019 This is the tourism including those forms of tourism that are directed towards physical health; nonetheless, they also improve mental and spiritual state as well as grow the chances of a person to satisfy one’s needs and act better in their own environment and society. Bulut and Sengul, 2019 The type of tourism allowing the health institutions to grow through the application of international potential of patients emerging due to the demand for diagnosis, treatment, and rehabilitation services. It could be stated that health tourism has emerged due to the people seeking treatment by travelling outside the borers of their own living place. Baltic Journal of Economic Studies 26 Vol. 9 No. 5, 2023 follows: it's a term that refers to travelling outside one's place of residence to other places with the aim of receiving treatment of various kinds, starting from medical intervention (voluntary or compulsory) to improve one's physical or mental well-being through traditional or alternative treatments, and ending with holistic medicine offered in SPA or wellness resorts ( Junio et al., 2016; Mainil et al., 2017). Treatments can range from highly invasive procedures (heart surgery, hip replacement, plastic surgery, etc.) to less invasive treatments (odontology) and wellness treatments (Reddy et al., 2010). Detailed health tourism services are shown in Figure 1. To summarise, the entire range of health tourism services can be divided/systematised by the nature of medical care, with the following subtypes identified: the medical direction of medical and wellness/SPA tourism with the aim of maintaining normal bodily functions in the conditions of existing or progressing chronic diseases; the preventive direction of medical tourism with the aim of preventing possible diseases as well as reducing the risk of disability due to the development of occupational diseases; the rehabilitative direction of medical and wellness/SPA tourism, with the aim of restoring the original physical condition after operations, infectious diseases or injuries, which includes the elements of physical activity and physiotherapy; the rehabilitative direction of medical and wellness/ SPA tourism, which includes the strengthening of mental health and psychosomatic balance through the combination of drugs and methods of emotional release; the direction of wellness/SPA tourism, which includes the strengthening of the body through the performance of special balanced physical activity; the aesthetic direction of wellness/SPA tourism, which adjusts one's appearance without operations. 3. Socio-Economic Impact of Health Tourism Despite the abundance and diversity of the existing scientific literature on human capital and the vast amount of research carried out in this area, there is little research on the economic aspects of health as an integral part of human capital. The lack of scientific literature on the impact of health tourism as the main component of human capital on health as well as the research and analysis carried out on the socio- economic aspect is present. Andreeva (2017) analyses the links between health tourism and human capital. The author notes that health tourism, as one of the key mechanisms for the development and quality of human capital, tends to have a positive impact on the healthcare system. She emphasises that the introduction of specialisation in the provision of health tourism services, as well as the specification of tourism offers, is an effective way of maintaining a high level of public health, increasing efficiency and achieving better health outcomes, as well as rationalising the expenditure aimed at achieving this goal. HEALTH TOURISM MEDICAL TOURISM WELLNESS/SPA TOURISM • Cancer treatment • Diagnostic tests (consultations with doctors, laboratory tests). • Cardiology/heart surgery. • Orthopaedic surgery (hip joint replacement, surface renewal, joint surgeries). • Odontology (cosmetics and reconstruction). • Neurosurgery. • Transplantation. • Bariatric surgery (gastric shunting, gastric banding). • Fertility / reproductive system (IVF, sex reassignment). • Cosmetic surgery (breast augmentation, plastic face surgery, fat removal etc.) • Transplantation of organs, cells, and tissues (stem-cell therapy). • Eye surgery. • And other. • Acupuncture. • Aromatherapy. • Day SPA. • Beauty care. • Face and body scrubbing. • Exercises and diet. • Holistic lifestyle. • Homoeopathy. • Hydrotherapy. • Hypnosis. • Massage. • Meditation. • Mud therapy. • Recollections. • Stress management. • Thalasotherapy. • Thermal streams/balneotherapy. • Yoga. • And other. Figure 1. Spectrum of health tourism services Source: compiled in accordance with (Henderson, 2003; Lunt et al., 2011; Hall, 2011; Lukowicki-Vikuk, 2012; Padilla-Melendez and Del-Aguila- Obra, 2016; Bulut and Sengul, 2019) Baltic Journal of Economic Studies 27 Vol. 9 No. 5, 2023 The latter problems tend to draw the attention of economists and specialists from other fields to the search for ways to improve and maintain public health, as well as to the rational approach to the distribution of financial resources within the healthcare system. Health tourism is an example of such means. Its specific forms and specialisations make a significant contribution to the treatment and prevention of diseases, as well as to health education, environmental education and the development of specific health intelligence. Each health dimension of physical, mental, emotional, social, spiritual and sexual health is significant both in the creation of the components of human capital and as a factor of its development (Andreeva, 2017). Good health, which increases the period of activity and physical readiness, positively influences social and professional activity. Research conducted by Doppelhofer et al. (2004) has shown that health is the most important component of human capital in terms of its impact on economic growth. Therefore, health interventions represent an investment in human capital (Hadzik et al., 2016). Despite the expenditure on health protection at national level, organisations suffer losses due to the deterioration in the health of their employees. Sick leave could be considered as a measure of impact. For instance, the increase in the number of sick leave days in Lithuania in 2018 compared to 2010 was 3.5 days (Public Health Monitoring Information System, 2018). This was determined by three main factors: emotional state, eating habits and lack of physical activity. The negative manifestation of these factors leads to various illnesses, the consequences of which could be prevented or reduced by health tourism. For example, the treatment of back pain symptoms using SPA treatments is a valuable form of treatment due to the complexity of methods used (balneotherapy, physiotherapy, etc.). Rehabilitation in a sanatorium or other institution provides better conditions for physical treatment and accelerates the return to social life. The Supreme Audit Institution of Lithuania (AAI, 2019) fulfilled the assessment of the healthcare system and identified the following key issues in 2019: – Availability of services is not guaranteed; – further training corresponding to needs is not appointed; – effective management of undesirable events is not guaranteed; – expensive equipment and new medical technologies are not used to the full extent; – unclear extent of services; – services are not clearly defined; – pricing for services is not based on objective costs. Thus, the development of the health tourism industry could be expected to make a positive contribution to solving the problems identified and to improving the healthcare system in general. NaRanong and NaRanong (2011), Beladi et al. (2019), Kostadinova and Katsarova (2019), Erdem (2021), Zhong (2021) and others analyse the impact of health tourism on both sending and receiving countries. The positive impact of health tourism on countries of origin Health tourism benefits sending countries in several ways. First, it increases the likelihood that residents of sending countries will receive healthcare services. Connell (2013) pointed out that patients, especially from developed countries, are motivated to seek treatment abroad due to the significant cost savings as well as dissatisfaction with the public healthcare system at home (i.e., long waiting lists and low quality of healthcare services). Matto and Rathindran (2006) compared treatment prices in 15 countries and estimated that if one in ten patients in the US were to receive treatment abroad, it would save about 1.35 billion EUR per year. The comparative analysis of health expenditure in India and the UK, taking into account the time spent waiting for a specific medical treatment, showed that it would be possible to save 135-230 million EUR by sending patients from the UK to India (Smith et al., 2011). Therefore, health tourism could be seen as a solution to the problem of unaffordable healthcare if tourists/ patients in sending countries could avoid waiting lists and high medical costs. Moreover, according to Helble (2011), since patients could be treated abroad under insurance programmes offered in the sending countries, competition among private health service providers in the home country of a patient/tourist could increase with the reduction of prices for the health services available. Second, health tourism increases the choice of patients/tourists, as those from the sending countries have the opportunity to receive treatment that is not available or prohibited in their home countries. In some countries that are less developed in terms of healthcare infrastructure, the costs of patients who travel to regional medical centres are subsidised to give them the opportunity to receive certain specialised medical services that are inaccessible or too expensive to provide at home (Beladi et al., 2019). Patients/tourists also travel abroad because certain healthcare treatments (e.g., stem cell therapy for Parkinson's disease and stroke, legally restricted assisted fertilisation, etc.) are prohibited in their countries (Hopkins et al., 2010; Medical Tourism Magazine, 2016). The negative impact of health tourism on the countries of origin. Despite its benefits, health tourism poses a threat to sending countries. Health tourists/ patients are at high risk of receiving poor quality Baltic Journal of Economic Studies 28 Vol. 9 No. 5, 2023 health services. Given the inherently dangerous nature of medical treatment, patients do not always fully understand the risks associated with a particular treatment, especially when receiving treatment abroad. Increasingly, potential health tourists/ patients trust information provided on the internet (hospital websites and health tourism applications), health tourism intermediaries or travel agencies specialising in health tourism (Moghavvemi et al., 2017). Based on an analysis of the content of websites promoting health tourism, Penney et al. (2011) found that around 29% of websites did not disclose the credentials of the providers of the medical services they advertised, while 47% did not mention the risks associated with the health services. The positive success rates of foreign hospitals for certain medical treatments are also unreliable, as the methods of measurement are rarely disclosed (Hopkins et al., 2010; Connell, 2013). Most foreign providers of medical services in the field of health tourism are accredited by international institutions ( JCI, ISQUA, etc.) and employ medical professionals trained in prestigious institutions in developed countries. However, post-operative infections and side effects have begun to cause concern. When patients travel abroad for treatment, they may not receive the usual care that they could receive at home. It is very common for many medical procedures to be carried out in a short period of time when being treated abroad, with the challenge of continuing to care for the tourist/patient (Lunt and Carrera, 2010). Furthermore, in the event of an urgent post-operative complication, it may be impossible for the patient/tourist to return to the same hospital for further treatment. In addition, in many developing countries where health tourism services are provided, there are no well-established medical malpractice laws or mechanisms for dealing with complaints after treatment, so patients who suffer complications or adverse effects have little recourse to the institution that provided the healthcare (Smith and Forgione, 2007). The positive impact of health tourism on host countries. The great interest in health tourism as one of the engines of economic growth of a host country, generating added value to the gross national product, could be linked to three main factors. First, health tourism receipts are recognised as a form of export that can generate foreign exchange income with the aim of improving the balance of payments of countries. The potential income for host countries includes revenue from health services provided to foreign patients/tourists, as well as expenditure by patients and their companions on food, accommodation and local tourism activities (Lautier, 2008). The importance of health tourism for the economy of a host country is reflected in the value of foreign exchange earnings and export growth. Beladi et al. (2019) in the research work carried out presents the survey of health tourists/patients in the cities of Kuala Lumpur, Musa, Thirumoorthi and Doshi fulfilled in 2012 and assumes that health tourists/patients spend about 12 times more than ordinary leisure tourists, with the total expenditure of a health tourist being on average ~6,000 EUR while the average expenditure of a leisure tourist is ~500 EUR. Klijs et al. (2016) confirmed the latter statement in their analysis of the economic impact of health tourism at the national level, which was fulfilled in Malaysia. The authors have used the input- output method to estimate the total value generated by health tourism in Malaysia in 2007, which amounts to ~ 280 million EUR and ~105 million EUR in value added. Health tourism stimulates growth in the local healthcare sector as well as in other industries such as retail, accommodation, food services, and transport with improved communication infrastructure, and so forth (Hopkins et al., 2010). Second, the growth of health tourism increases employability in the health sector and other related industries. Lautier (2014) has estimated that in 2005 health tourism in Tunisia created 37,000 jobs, of which 18,000 were created in the health sector and 19,000 in tourism-related industries. Klijs et al. (2016) have analysed the case of Malaysia and provided data that in 2007 health tourism in Malaysia created 19,587 job positions, of which 14,839 were in the healthcare sector. Private hospitals offering health tourism (especially medical tourism) services tend to offer more profitable salaries, better working conditions and more promising career opportunities for health professionals compared to public hospitals with the gap between domestic salaries and those offered abroad. By reducing the salary gap, jobs in the home country become more attractive; therefore, private healthcare providers not only try to stop the migration of highly qualified healthcare professionals to other countries (external brain drain), but also encourage those living abroad to return home (Beladi et al., 2019). Third, health tourism improves access to domestic health services and provides the basis for the growth of quality health services in developing countries. Usually, healthcare services are developed in the private sector; however, some public hospitals have also established private healthcare units and provide healthcare services to foreign patients/tourists. In order to attract foreign patients/tourists, private healthcare providers in host countries are consistently increasing investment in upgrading their healthcare facilities and training and attracting highly qualified healthcare workers. As the healthcare sector is highly capital-dependent, promoting health tourism offers hospitals in countries with small populations, such as Singapore, the opportunity to achieve economies Baltic Journal of Economic Studies 29 Vol. 9 No. 5, 2023 of scale by fully exploiting extensive potential and justifying investment in expensive advanced medical technologies (Hopkins et al., 2010). In addition, some developing countries, seeking to consolidate their position as high-quality destinations for health tourism, have introduced tax rebates for the construction of medical centres and the purchase of medical equipment, as well as tax exemptions on income from foreign patients, in order to attract foreign direct investment in the health sector (Chee, 2010). To ensure the quality of healthcare facilities, most private healthcare providers tend to establish relationships with reliable healthcare providers in the US, such as The Johns Hopkins Hospital, Medical School and Mayo Clinic, or obtain accreditation from Joint Commission International, the international accreditation organisation for healthcare centres (Lunt et al., 2011). In order to maintain international cooperation links and accreditation, it is necessary to invest in developing the skills of healthcare professionals and in advanced medical technologies. It can be said that the above-mentioned initiatives not only increase the recognition of a particular country in the field of health tourism, but also create favourable conditions for the use of modern and high-quality services of healthcare institutions. Negative impact of health tourism on host countries. Despite the positive effects of health tourism, some researchers (e.g., Chen and Flood, 2013; Reisman, 2015; Zhang et al., 2022) have expressed strong concerns about the possible negative effects on the economy of receiving countries, especially in the case of developing countries, while developing the health tourism sector. Researchers have emphasised that the development of health tourism could lead to an inappropriate distribution of public resources in receiving countries. The health services most frequently sought by tourists/patients are arbitrary services, which differ from the health service needs of the local population. Countries developing health tourism tend to develop competitive advantages in specific areas of health services. For example, Singapore specialises in the treatment of various oncological diseases, India specialises in orthopaedic surgery and cardiology, while Thailand specialises in cosmetic surgery, cardiology and orthopaedic surgery (Gan and Frederick, 2011). The consequence of maintaining a competitive advantage in these healthcare areas is excessive investment in high-tech medical equipment and concentration of human capital in choosing specialisations in specific areas, rather than choosing areas with a broader profile to meet the healthcare needs of local residents. NaRanong and NaRanong (2011) claim that with the growth of the health tourism sector, the prices of healthcare services in a particular destination may increase and healthcare may become less accessible to local residents. Private healthcare institutions in developing countries may be owned by foreign investors who may not have an interest in the well-being of the local population ( Johnston et al., 2010). Such foreign investors may be eligible for government subsidies that exempt them from profit taxes or lower import tariffs; therefore, the income from health tourists/patients in a host country would not be subsidised within the public health system. The generalised impact of health tourism on the countries that send and receive tourists is shown in Figure 2. The analysis of the research literature has shown that it could be possible to claim that without an appropriate regulatory mechanism and monitoring of health services aimed at ensuring a fair and equitable distribution of the revenues generated by health tourism activity, it could become difficult for social groups with low incomes to access timely health services. Thus, in developing the health tourism industry, special attention should be paid to ensuring equal access to health services for all social groups. 4. Conclusions The analysis of the concept of "health tourism" has shown that health tourism is a term that covers travel from one's own territory of residence to other territories in order to receive various types of treatment (ranging from medical interventions (voluntary or compulsory)), improving physical or mental health through traditional or alternative treatments, and ending with holistic medicine offered at SPA and wellness resorts. The concept of health tourism can be divided into two main components: medical tourism (reactive medical services) and wellness or SPA tourism (proactive medical services). The socio-economic impact of health tourism can be divided into two areas: for the sending countries (positive – increased opportunities for tourists/ patients to receive health services, increased competitiveness of health services, expanded range of health services; negative – risk of low quality of health services, it's difficult to guarantee further care for a tourist/patient, insufficient mechanism for evaluating medical errors); for the receiving countries (positive – improved access to domestic health services, basis for qualitative growth of health services, income from improved balance of payments of a country, etc., strengthening of preventive healthcare, increasing employability of health professionals; negative – domestic brain drain, excessive competition between domestic and foreign tourists/patients, increase in destination prices of health services, narrowing of medical specialisation, inappropriate distribution of public resources). Baltic Journal of Economic Studies 30 Vol. 9 No. 5, 2023 References: Akgün, A. E., & Kirçovali, S. Y. (2015). Organizational wisdom and its impact on firm innovation and performance. Doğuş Üniversitesi Dergisi, (16) 2, 193–202. Available at: http://journal.dogus.edu.tr/index.php/duj/article/view/895 Baukutė, G. (2012). Medical tourism: the analysis of positive aspects of establishing medical tourism sector in Lithuania. Available at: http://www.etd.ceu.hu/2012/baukute_gabija.pdf Bajwa, S. U., Kitchlew, N., Shahzad, K., & Rhman, K. U. (2018). Public–Private Partnership (PPP) as an Interdependent Form (I-Form) Organization. International Journal of Public Administration, (41) 11, 859–867. DOI: https://doi.org/10.1080/01900692.2017.1298610 Bierly P. E. III, Kessler E. H., & Christensen E. W. (2000). Organizational learning, knowledge and wisdom. Journal of Organizational Change Management, (13) 6, 595–618. ISSN: 0953-4814 Andreeva, N. (2017). Wpływ turystyki zdrowotnej na kapitał ludzki. Wybrane aspekty. Studia i Prace WNEIZ US, (42) 2, 9–18. DOI: https://doi.org/10.18276/sip.2017.47/2-01 Abd Rashid, I. M., Ibrahim, S., & Yusoff, W. S. (2020). Recent Performance in Singapore's Tourism Industry Using normality Test, Correlation&Regression Analysis: The Effect of Medical Tourism, Service Sector & Exchange Rate. European Journal of Molecular & Clinical Medicine, (11) 7, 209–216. ISSN 2515-8260. Beladi, H., Chao, C.-C., Ee, M. S., & Hollas, D. (2019). Does Medical Tourism Promote Economic Growth? A Cross- Country Analysis. Journal of Travel Research, (58) 1, 121–135. DOI: https://doi.org/10.1177/0047287517735909 Bulut, A., & Sengul, H. (2019). Health Tourism in Turkey and The World. Journal of Management, Economic and Marketing Research, (3) 1, 45–62. DOI: https://doi.org/10.29226/TR1001.2019X Baukutė, G. (2012). Medical tourism: the analysis of positive aspects of establishing medical tourism sector in Lithuania. Public Policy Master’s Theses, Central European University, Budapest, Hungary. Available at: https://www.etd.ceu.edu/2012/baukute_gabija.pdf IMPACT OF HEALTH TOURISM ON SENDING COUNTRIES POSITIVE NEGATIVE Increases the chances of tourists/patients to receive medical services Increased competitiveness of healthcare services Expanding the range of medical services Risk of receiving low-quality medical services It is difficult to guarantee further care for the tourist/patient Imperfection of the mechanism of complaints and assessment of medical errors RECEIVING COUNTRIES POSITIVE NEGATIVE Income received, countries' balance of payments, etc. Increased employment opportunities for healthcare professionals Improved access to medical services Improper allocation of public resources Medical specialisation is narrowing Local prices for medical services are rising The basis for the growth of quality healthcare services is provided Preventive healthcare is strengthened Internal brain drain Excessive competition between local and foreign tourists/patients Figure 2. Socio-economic impact of health tourism on the countries that send and receive tourists Baltic Journal of Economic Studies 31 Vol. 9 No. 5, 2023 Benhacine, D., Hanslbauer, T., & Nungesser, S. (2008). German Health and Wellness Vacationers: Market Analysis and Recommendations. Selective Tourism, (3) 1, 32–52. Chee, H. L. (2010). Medical Tourism and the State in Malaysia and Singapore. Global Social Policy, (10) 3, 336–357. DOI: https://doi.org/10.1177/1468018110379978 Chen, Y. Y., & Flood, C. M. (2013). Medical tourism's impact on health care equity and access in low- and middle-income countries: making the case for regulation. J Law Med Ethics, (41) 1, 286–300. PMID: 23581671. DOI: https://doi.org/10.1111/jlme.12019 Connell, J. (2013). Contemporary medical tourism: Conceptualisation, culture and commodification. Tourism Management, (34), 1–13. DOI: https://doi.org/10.1016/j.tourman.2012.05.009 Cohen, E. (2008). Medical Tourism in Thailand. AU-GSB e-journal, (1) 1, 24–37. Available at: http://www.assumptionjournal.au.edu/index.php/AU-GSB/article/view/381/335 Dragičević, D., & Paleka, H. (2019). Health tourism market in Poland and Croatia – financial effects and potentials. Tourism in Southern and Eastern Europe, (5), 219–232. DOI: https://doi.org/10.20867/tosee.05.5 Erdem, H. (2021). The Role of Health Tourism in the Development of the Country and its Impacts on Employment. PhD thesis: Istanbul Rumeli University. European Commission (2015b). Cross-border healthcare report highlights advances and efforts at EU and national levels. Health and Food Safety, 3 September. Available at: http://ec.europa.eu/dgs/health_food-safety/ dyna/enews/enews.cfm?al_id=1616 Fetscherin, M., & Stephano, R. M. (2016). The medical tourism index: Scale development and validation. Tourism Management, (52), 539–556. DOI: https://doi.org/10.1016/j.tourman.2015.08.010. Faisal, M., & Dhusia, D. K. (2020). Health Tourism: A New Driver for Development. Advances in Economics and Business Management (AEBM), (7) 2, 50-56. e-ISSN: 2394-1553. Gan, L. L., & Frederick, J. R. (2011). Medical tourism facilitators: Patterns of service differentiation. Vacation Marketing, (17) 3, 165–183. DOI: https://doi.org/10.1177/135676671140918 Global SPA Summit (2011). Wellness Tourism and Medical Tourism: Where Do Spas Fit? Available at: http://www.espalibrary.eu/search/1048/ Hopkins, L., Labonte, R., Runnels, V., & Parker, C. (2010). Medical Tourism Today: What Is the State of Existing Knowledge? Journal of Public Health Policy, (31) 2, 185–198. DOI: https://doi.org/10.1057/jphp.2010.10 Helble, M. (2011). The Movement of Patients across Borders: Challenges and Opportunities for Public Health. Bulletin of the World Health Organization, (89), 68–72. DOI: https://doi.org/10.2471/BLT.10.076612 Hadzik, A., Tomik, R. & Ryśnik, J. (2016). Determinanty rozwoju turystyki zdrowotnej. Ekonomiczne Problemy Turystyki, (33) 1, 287–300. DOI: https://doi.org/10.18276/ept.2016.1.33-23 Hall, C. M. (2011). Health and medical tourism: a kill or cure for global public health? Tourism Review, (66) 1/2, 4–15. DOI: https://doi.org/10.1108/16605371111127198 Henderson, J. C. (2003). Healthcare tourism in Southeast Asia. Tourism Review International, (7), 111–122. DOI: https://doi.org/10.3727/1544272031437692 Harasim, B. (2014). Turystyka zdrowotna jako czynnik rozwoju gospodarki Podlasia. PhD Theses. Uniwersytet Zielonogórski. Available at: http://hdl.handle.net/11320/1103 Hodžić, S., & Paleka, H. (2018). Health Tourism in the European Union: Financial Effects and Future Prospects. 9th International Conference of the School of Economics and Business Conference Proceedings, 162–174. Johnston, R., Crooks, V. A., Snyder, J., & Kingsbury, P. (2010). What Is Known about the Effects of Medical Tourism in Destination and Departure Countries? A Scoping Review. International Journal for Equity in Health, (9), 1–13. Available at: https://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-9-24 Junio, M. M. V., Kim, J. H., & Lee, T. J. (2016). Competitiveness attributes of a medical tourism destination: The case of South Korea with importance-performance analysis. Journal of Travel & Tourism Marketing, (34) 4, 444–460. DOI: https://doi.org/10.1080/10548408.2016.1182454 NaRanong, A., & NaRanong, V. (2011). The effects of medical tourism: Thailand’s experience. Bulletin of the World Health Organization, (89) 5, 336–344. DOI: http://dx.doi.org/10.2471/BLT.09.072249 Klijs, J., Ormond, M., Mainil, T., Peerlings, J., & Heijman, W. (2016). A State-Level Analysis of the Economic Impacts of Medical Tourism in Malaysia. Asian-Pacific Economic Literature, (30) 1, 3–29. DOI: https://doi.org/10.1111/apel.12132 Kostadinova, T., & Katsarova, S. (2019). The importance of the European health tourism for the development of economy of wellbeing. In book: 4th International Thematic Monograph: Modern Management Tools and Economy of Tourism Sector in Present Era. DOI: https://doi.org/10.31410/tmt.2019.527 Keliauk Lietuvoje (2021). Turizmo sektoriaus plėtros tyrimas. Available at: https://lithuania.travel/uploads/ ataskaitos/Turizmo_sektoriaus_pl%C4%97tros_tyrimas.pdf Kim, S., Arcodia, C., & Kim, I. (2019). Critical success factors of medical tourism: The case of South Korea. Environmental Research and Public Health, (16), 1–16. DOI: https://doi.org/10.3390/ijerph16244964 Lautier, M. (2008). Export of Health Services from Developing Countries: The Case of Tunisia. Social Science & Medicine, (67), 101–110. DOI: https://doi.org/10.1016/j.socscimed.2008.01.057 Baltic Journal of Economic Studies 32 Vol. 9 No. 5, 2023 Lautier, M. (2014). International trade of health services: Global trends and local impact. Health Policy, (118) 1, 110–113. DOI: https://doi.org/10.1016/j.healthpol.2014.07.004 Lunt, N., & Carrera, P. (2010). Medical Tourism: Assessing the Evidence on Treatment Abroad. Maturitas, (66), 27–32. DOI: https://doi.org/10.1016/j.maturitas.2010.01.017 Lukowicki-Vikuk, A. P. (2012). Turystyka medyczna przejawem współczesnych trendów i tendencji w turystyce. Ekonomiczne problemy usług, (84), 553–568. ISSN 1640-6818. Moghavvemi, S., Ormond, M., Musa, G., Mohamed Isa, C. R., Thirumoorthi, T., Mustapha, M. Z., Kanapathy, K., & Chandy, J. J. C. (2017). Connecting with Prospective Medical Tourists Online: A Cross- Sectional Analysis of Private Hospital Websites Promoting Medical Tourism in India, Malaysia and Thailand. Tourism Management, (58), 154–163. DOI: https://doi.org/10.1016/j.tourman.2016.10.010 Medical Tourism Magazine (2016). What an NHL Player Taught the Medical Tourism Community about the Right to Try. Available at: http://www.medicaltourismmag.com/the-right-to-try-laws/ Mattoo, A., & Rathindran, R. (2006). How Health Insurance Inhibits Trade in Health Care. Health Affairs, (25) 2, 358–368. DOI: https://doi.org/10.1377/hlthaff.25.2.358 Mainil, T., Eijgelaar, E., Klijs, J., Nawijn, J., & Peeters, P. (2017). Research for TRAN Committee – Health tourism in the EU: a general investigation. European Parliament, Policy Department for Structural and Cohesion Policies, Brussels. Available at: http://www.europarl.europa.eu/RegData/etudes/STUD/2017/601985/ IPOL_STU(2017)601985_EN.pdf Ormond, M., & Lunt, N. (2019). Transnational medical travel: Patient mobility, shifting health system entitlements and attachments. Journal of Ethnic and Migration Studies, (46) 20, 4179–4192. DOI: https://doi.org/10.1080/ 1369183X.2019.1597465 Penney, K., Snyder, J., Crooks, V. A., & Johnston, R. (2011). Risk Communication and Informed Consent in the Medical Tourism Industry: A Thematic Content Analysis of Canadian Broker Websites. BMC Medical Ethics, (17), 1–9. DOI: https://doi.org/10.1186/1472-6939-12-17 Padilla-Melendez, A., & Del-Aguila-Obra, A. R. (2016). Health Tourism: Conceptual Framework and Insights from the Case of a Spanish Mature Destination. Tourism & Management Studies, (12) 1, 86–96. DOI: https://doi.org/10.18089/tms.2016.12109 Reddy, S. G., York, V. K., & Brannon, L. A. (2010). Travel for treatment: Students' perspective on medical tourism. International Journal of Tourism Research, (12) 5, 510–522. The assessment of healthcare system April 15, no. YD-4. Available at: https://webcache.googleusercontent.com/ search?q=cache:CVqmuB0vaLMJ Smith, P. C., & Forgione, D. A. (2007). Global Outsourcing of Healthcare: A Medical Tourism Decision Model. Journal of Information Technology Case and Application Research, (9) 3, 19–30. DOI: https://doi.org/10.1080/ 15228053.2007.10856117 Smith, R., Alvarez, M. M., & Chanda, R. (2011). Medical Tourism: A Review of the Literature and Analysis for a Role for Bi-lateral Trade. Health Policy, (103), 276–282. DOI: https://doi.org/10.1016/j.healthpol.2011.06.009 Szromek, A. R., Puciato, D., Markiewicz-Patkowska, J. I., & Colmekcioglu, N. (2023). Health tourism enterprises and adaptation for sustainable development. International Journal of Contemporary Hospitality Management, (35) 1, 1–25. DOI: https://doi.org/10.1108/IJCHM-01-2022-0060 World Tourism Organization (2018). UNWTO Tourism Highlights. Available at: https://www.e-unwto.org/doi/ pdf/10.18111/9789284419876 Vega-Vázquez, M., Rodríguez-Serrano, M. A., Castellanos-Verdugo, M., & Oviedo-García, M. A. (2021). The impact of tourism on active and healthy ageing: health-related quality of life. Journal of Policy Research in Tourism, Leisure and Events, (13) 3, 349–373. DOI: https://doi.org/10.1080/19407963.2020.1837844 Wong, B. K. M., & Sa’aid Hazley, S. A. (2021). The future of health tourism in the industrial revolution 4.0 era. Journal of Tourism Futures, (7) 2, 267–272. DOI: https://doi.org/10.1108/JTF-01-2020-0006 Zhong, L., Deng, B., Morrison, A. M., Coca-Stefaniak, J. A., & Yang, L. (2021). Medical, Health and Wellness Tourism Research – A Review of the Literature (1970–2020) and Research Agenda. Int. J. Environ. Res. Public Health, (18). DOI: https://doi.org/10.3390/ijerph182010875 Zhang, W., Qin, Z., & Tang, J. (2022). Economic Benefit Analysis of Medical Tourism Industry Based on Markov Model. Hindawi, Journal of Mathematics. DOI: https://doi.org/10.1155/2022/6401796 Received on: 10th of October, 2023 Accepted on: 28th of November, 2023 Published on: 28th of December, 2023