Alternative Tourism Initiative: The Project of Thermal Complex Investment Analysis and Feasibility Report Final Report Project Owner: Çubuk District Governorate T.R. Ankara Develeopment Agency 2012 Direct Action Incentive Program, Reference Number: TR51/12/DFD

Competition Research Center School ofManagement, Yıldırım Beyazıt University

Res. Asst. Merve Acar Prof. Dr. Dilek Demirbaş Res. Asst. İklim Gedik Asst. Prof. Dr. H. Kemal İlter August, 2012

    

REKMER Competition Research Center Yıldırım Beyazıt University, School of Management

Cinnah Cad. No: 16 Kavaklıdere Ankara Turkey

www.rekmer.org

This report has been prepared within the context of The Project of Thermal Complex Investment Analysis and Feasibility Report Project of Alternative Tourism Initiative supported by T. R. Ankara Development Agency. Content and sole responsibility belongs to Governorate of Çubuk District. It does not reflect the opinions

of T R Ankara Development Agency

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FOREWORD

Tourism is defined as a social, cultural and public service providing self- rejuvenation and recreation in terms of bodily and spiritual rest within rapid industrialization and urbanization. According to World Tourism Organization's March 2012 statistics, the "incoming tourist" number for 150 member States has reached 980 million. Tourism sector achieved $6.5 trillion volume within global economy and created employment for 260 million. Put differently, one out of every 12 businesses in the world is connected with tourism. According to the data from World Tourism Organization, within the total tourism 51% was for culture, entertainment and vacation; 15% was hospitality tourism for business and professions; 27% for friends and relatives visits, health as well as faith and pilgrimage tourism, and the undeclared was 7%.

Mobility of people seeking health care outside of their residential areas through travel and lodging has led to a specific type referred to as Health Tourism. According to the World Tourism Organization, visits to thermal springs and/or other health centers with the aim of improving a person's physical well-being are included in the health tourism. To a significant extent the health tourism involves thermal springs. Many civilizations developed bath and massage cultures, and primitive thermal tourism predominantly in the classic period Ionia and latter Roman Empire since the identification of positive health impact of hot springs during BC 1700s. Research done by International Spa Association(ISPA) in 2007 estimated that approximately 100 million individuals worldwide have travelled for thermal tourism.

In the area of health tourism, especially during the past two decades, Turkey has made significant progress and began to compete with countries seen as most successful, such as India, Malaysia, Thailand and Hungary. Due to its geographical location Turkey has a characteristic structure with its deep tectonic fault lines and mineral wealth. Positioned on an important geothermal belt known as young mountain range Alpine-Orogenic Belt, our country's thermal waters present in more than 2000 springs are rated first in Europe in terms of their flowrates, temperatures and varying physical as well as chemical properties, and third in terms of hotspring facilities. While this is the case, only 1300 therapeutic water sources possess thermal spring characteristics and so far only

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102 of these were thermally classified. For this reason, the question of thermal resource studies confronts us as a substantially significant subject in the support of health tourism and provision of relevant public services.

Due to its higher service quality standards Ankara with its therapeutic spring resources can make an important contribution in the area as an health tourism urban center. As a consequence of Ankara’s leadership in the health tourism sector and with increased number of visitors arriving for therapy and other needs from surrounding provinces and abroad, the sector including the medical tourism, thermal/SPA-wellness and advanced age/handicapped tourism can contribute to the province's economic and social development and render it a competitive touristic urban center.

In this context and with the financial support of Ankara Development Agency founded for Ankara's economic and social development, and on the basis of a request from the Governorate of Çubuk, we hope that this report which is the result of a concentrated effort would make a contribution to the regional development of Ankara. In the light of this general framework and for the invaluable contributions made to this report, we extend our gratitude to the executives and employees of project owner Çubuk Governorate, project participant Çubuk Municipal Administration and its subcontractor Competition Research Center(REKMER) at the School of Management, Yıldırım Beyazıt University.

Project Team

Res. Asst. Merve Acar Prof. Dr. Dilek Demirbaş Res. Asst. İklim Gedik Asst. Prof. Dr. H. Kemal İlter Ankara, 2012

1 INTRODUCTION TO PROJECT OF THE R-ATG

1.1. Specification of the R-ATG Project

Project Code R-ATG

Project Title Alternative Tourism Initiative: Thermal Complex Investment Analysis and Feasibility Report

Project Owner Governorate of Çubuk

Project Partners Çubuk Municipal Administration

Yıldırım Beyazıt University Funding T.C. Ankara Development Agency, 2012 Direct Action Support

Program

Reference Number: TR51/12/DFD Project Duration 12 June-22 August 2012

(Initiated on April 22nd with a 3 month project period, REKMER joined the project on 11 June 2012)

Project subject region is shown in Figures 1, 2 and 3.

Figure 1: Çubuk district, Ankara

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Figure 2: Yıldırım Beyazıt University Campus – 1

Figure 3: Yıldırım Beyazıt University Campus – 2

1.2. Objectives of the R-ATG Project

General purpose of this project:

“Is the identification of tourism vision, strategy and policies in collaboration with university-local administration-civil organizations by establishing thermal tourism potential of the Province of Ankara and in particular of Çubuk district (in the vicinity of Esenboğa Airport) in order to render the region a center of attraction for national and foreign tourists.”

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Project's special aims are as follows:

1. Identification of strategies and objective investment projects for transforming Ankara's provincial thermal tourism potential into practice,

2. Determination of a road-map for optimal planning and execution of a thermal complex intended within the University campus,

3. Formation of university, local administration and civil organizations collaboration for the development of thermal tourism infrastructure and increasing of regional tourism potential,

4. Improvement of employment potential by regional alternative tourism investments,

5. Offering a hotspring tourism complex infrastructure including hospital and cure center expertise requiring services within the context of the University.

1.3. Expected Short-term Results of the Project

1. Establishment of the investment and operational model of the Thermal Complex planned for Esenboga through identification of health tourism vision and regional strategic objectives for Ankara.

2. Within the framework of permits obtained from the General Directorate of Mineral Research and Exploration for the Thermal Complex(thermal water well analysis, use rights, etc.) area, submitting of required applications to the Ministries of Tourism and Health.

3. Initiation of awareness creation on Health Tourism within the Ankara Region, and bringing of sectoral stakeholders together.

4. Definition of the Faculty of Medicine of Yıldırım Beyazıt University, the new State institution in Ankara and which began its foundation activities in the area of intended complex, as an effective stakeholder within the context of Health Tourism.

5. Establishment of a Web portal for wide dissemination of project results and for introduction of thermal complex to national and international investors, and initiation of relevant discussions with investors.

1.4. Expected Mid- and-Long Term Results of the Project

1. In the mid-term, primarily physical establishment of the thermal facility and commencement of operations in the Esenboğa area.

2. Clear and strategic positioning of health tourism in Ankara as an alternative tourism sector within the regional economy will be an important result in the long-term. Employment creation and capacity expansion effects in related sectors are siginificant economic gains.

3. Important progress will be achieved in public, university and private sector cooperation within the health tourism sector, and this collaboration will yield concrete projects.

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4. Increases in the number of national and foreign health tourists in particular will have positive effects on the region.

5. In the long-term, this Complex's (as an thermal water and cure therapy) raising of the bar to a higher point in Ankara region can be defined as another positive result.

1.5. Performance Indicators of Expected Results

1. Numbers of national and foreign health tourists arriving at the region. 2. International flight increases at the Esenboğa Airport. 3. Expansion of vertical and horizontal sectoral and multi-sectoral cooperation

capacity. 4. Increased regional employment in the alternative tourism area. 5. Increased investment capacity in the tourism sector and supporting sectors.

1.6. Sources of Validation for the Indicators

1. Ministry of Tourism data(tourist numbers and tourism investment licenses). 2. Ministry Health-Health Tourism Coordination data. 3. Esenboğa Airport international passenger traffic. 4. TÜİK tourism data(Statistics Institute of Turkey). 5. İŞKUR data(State Employment Agency). 6. Ministry of Finance data.

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2 ALTERNATIVE TOURISM: ANALYSIS OF SECONDARY DATA CONCERNING HEALTH TOURISM

Tourism is defined as the social, cultural and public service providing self- rejuvenation and recreation in terms of bodily and spiritual rest within rapid industrialization and urbanization. According to World Tourism Organization's March 2012 statistics, the "incoming tourist" number for 150 member States has reached 980 million. Tourism sector achieved $6.5 trillion volume within global economy and created employment for 260 million. Put differently, one out of every 12 businesses in the world is connected with tourism.

According to the data from World Tourism Organization, within the total tourism 51% was for culture, entertainment and vacation; 15% was hospitality tourism for business and professions; 27% for friends and relatives visits, health as well as faith and pilgrimage tourism, and the undeclared was 7%.

Alternative Tourism Concept and Definition

Ministry of Culture and Tourism defines alternative tourism as “a type of tourism with the aim of giving priority to social and ecological harmony, collaboration of national and international entrepreneurs, and utilization of national resources in development."

Key factors which enabled emergence of the alternative tourism concept can be classified as awareness of the increasing negative impact of tourism on the environment, increased number of tourists seeking new touristic activities, economic and environmental factors progressively gaining importance, and sliding of general inclinations in the tourism market toward alternative tourism variety (Yıldız&Kalağan, 2010).

Whereas in Turkey, it is possible to mention two categories in alternative tourism. First category is the variety including nature and health, faith based, ballooning and sports. Connected with the first, second category involves camp and caravan, winter, bird watching, hunting and golfing tourism (Oral&Tavmergen,1998). This study will deal with the health tourism variety of alternative tourism, in particular with thermal tourism.

Concept of Health Tourism and Definition

According to the World Tourism Organization “Visits made to the hotsprings and other health centers for the purpose of improving individual's physical

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wellbeing" are included in the health tourism. Physical therapy, diet control and relevant health services are offered within its scope. Ministry of Culture and Tourism defines it briefly as "travels made for the purpose of therapy". Aydın (2012) states that health tourism emerged as a special form of tourism as a consequence of travel and accomodation due to "people's desire for treatment outside of their residential areas." Target of health tourism can be seen to consist of "individuals with poor health and persons conscious of health protection"(Ministry of Tourism, 1993).

Although it involves thermal tourism to a great extent, health tourism is a much wider concept beyond it. Within the scope of health tourism, the possibility of forming health centers at vacation areas for people who prefer to receive treatments such as plastic surgery, psychiatry, rehabilitation outside of their normal areas of residence, and perception of holidays as part of threapy were investigated.

In contrast, it would be more appropriate to refer to the international travelling made for the purpose of receiving certain medical treatments in hospitals as "Medical Tourism". Various forms of treatment such as plastic surgery, eye defect removal surgeries, open heart surgeries, all types of cancer and dental treatments, even organ transfers are inlcuded in this category.

During recent years, the concept of being healthy moved to the forefront as never before. The theme of being removed from the business environment and regaining health in warm climates and waters is more predominant than entertainment. While the health tourism generally encompasses concepts of being healthy and remaining vigorous, medical intervention and treatment seeking travel is being understood by medical tourism. In its simplest definition health tourism is used to express travels made for the purpose of receiving treatment. But when its wide spread use is examined, health tourism refers to various non-classic medical applications which can be categorized under the title of SPA and hotsprings tourism.

Gonzales, Brenzel & Sancho (2001:20) investigate health tourism services under three main headings:

Services For Health Improvement (hotsprings, herbal tretaments, massage, etc.)

Therapeutic Services (plastic, heart, eye surgeries, cancer treatment, etc.) Rehabilitation Services(such as dialysis, addiction programs, old age care)

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2.1. Historical Development of Health Tourism

In reality, the past of health tourism dates back to ancient ages. While patients visited Mediterranean regions for thermal water therapy during the classical Greece, after the 18th century, rich Europeans travelled to the river Nile for hotsprings, and now in the 21st century they travel for therapy to relatively inexpensive locales where waiting periods are short.

Initial forms of health tourism involved mostly remaining vigorous and during the 18th century hotsprings in Europe gained popularity. With the arrival of 19th century, health improving effects of tropical climates in distant colonies such as New Caledonia in the French Pacific were brought to the forefront and used for tourism (Smyth 2005). Later this tourism was transformed into beach tourism and became an activity which benefited not only the wealthy but also the working middle-class (Gilbert 1954).

Sports such as golfing, cycling, hiking, climbing became activities combining tourism with being healthy. Lately, yoga and meditation tourists are also seen. As seen in the Kırgızistan example, hotsprings tourism is a leader in this category (Connell, 2006: 1093-1100).

With some exceptions, hotsprings tourism involves activities for remaining vigorous rather than treatment. Today health tourism exceeds the dimensions of classic hotsprings tourism. While on the one hand traditional therapies are used, on the other preventative surgical and rehabilitative treatment methods are employed in order to improve the effectiveness of care. Aim is to offer health protection and rehabilitation programs in positive and temperate climatic conditions to those requiring rehabilitation and to the 3rd age group.

What is expected of tourism is rest, happiness and of course contribution to health. People's interest in health oriented activities such as hotsprings caused the development of health tourism concept.

In recent years the concept of being healthy gained much importance. Rather than entertainment, distancing oneself from the stress of work environments and rejuvenation in warm climates is the leading theme. While health tourism generally encompasses the concepts of being healthy and remaining vigorous, medical intervention and treatment seeking travel is being understood by medical tourism (Connell, 2006: 1093-1100).

2.2. Reasons of Health Tourism and Its Types

Departure point of treatment seeking travels were increased health expenditures in developed countries, rise in populations, difficulties of social security systems

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and higher cost of medical care, rapidly ageing population, and advances in means of transportation. Advances in communication and information technologies providing ease of access to all types of data became a pushing force for treatment seeking travelling. This emerging market raises the appetite of health service providers.

According to data from the World Tourism Organization, worldwide international arrivals are expected to reach 1.6 billion in the year 2020. Health tourism is estimated to have reached US$100 billion volume in 2012 and reached a point of great interest for many countries. It is calculated that by 2017, only from the USA, 23 million potential patients will travel overseas for health tourism with an expenditure of US$79.5 billion.

Thermal Tourism, Spa-wellness

Oldest known type is the thermal and spa-wellness tourism dating back to BC 1700 when therapeutic effects were noted and in many civilizations led by Ancient Rome and Classic Ionia, bath and massage cultures were developed. International Spa Association's 2007 survey showed that nearly 100 million tourists worldwide travelled for spa tourism.

Medical Tourism

Medical tourism covers the travels done for the purpose of seeking medicinal tretament. All medical intervention done within the scope of medical tourism is conducted under the supervision of doctors in fully equipped hospitals or polyclinics.

Advanced Age Tourism

This is a type of health tourism involving medical care of persons age 65 or older in particular.

2.3. Medical Tourism

Medical tourism requires a multidisciplinary perspective including medical diagnosis, treatment, rehabilitation applications, accomodations, agencies, advertising, environment and architecture, economics. etc. Medical tourism may also be defined as travelling abroad for treatment including medicine, surgery and/or dentistry. On occasion medical tourism has been defined differently by various people. Some of these are: Van Sliepen defines medical tourism as journeys done for the purpose of treatment at opportune times with accomodation other than at personal residence (Harahsheh, 2002).

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According to Magablih (2001) medical tourism is going to another country for not less than 24 hours and not exceeding one year for the purpose of healing or regulating their health status with the exception of intent for work or settlement.

Medical tourism which can also be defined as receiving emergency medical services in other countries is growing every passing day. Patients have different reasons for travelling abroad. In England, patients know that they can receive medical treatment services abroad for half or at a fraction of cost, and they participate in medical tourism.

Wheras in Canada patients complain of long waiting periods and wish to get medical treatment in another country. Patients from countries such as Bangladesh travel abroad due to lack of required treatment opportunities in their country. And for some patients the advantage of combining vacation with treatment is the reason for travelling abroad (http://www.cbc.ca, 2006, May 17).

Medical tourism is the collaboration with tourism industry with the objective of providing "cost effective" special treatment and care generally involving surgery or other medical interventions requiring expertise. Medical tourism has been transformed into a general vacation type and covers nearly all instances of medical services. It brings together entertainment, relaxation and treatment. Its focal idea is to be removed from daily routine, to receive treatment in a comfortable and different environment or health supporting services. One can enjoy being near the mountains and sea, and benefit from services which will improve one's health. It is also possible to conceive it as spiritual, emotional and physical renewal. Overseas medical tourism is an approach combining vacation and medical treatment which emerged as a consequence of the development of medical industry in countries abroad (Connell, 2006).

Main region of medical tourism is Asia. Thailand earned a reputation in gender modification during the 1970s and later began to specialize in plastic surgery. Maleysia joined the group after the economic crisis in 1998 when local patients in Thailand were unable to meet the costs. Singapore, having entered the market later, lowered the prices in order to compete with Thailand and Maleysia, and placed information booths at its airports advertising medical tourism alternatives (Connell, 2006: 1093-1100).

Today, India is seen as the leading country in this arena. While India aims to treat patients from Europe, Middle East and Canada, Singapore aims to treat patients from the USA (CBC News; 2007). Medical tourism emerged as as a type of health tourism during mid-1990s.

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While Singapore is a relatively expensive stop in thermal tourism travels, it desires to atttact 1 million patients expected to provide a revenue of US$1 billion. If this target is met at least 13 thousand new jobs will be created in the country.

Phillipines showed its interest in medical tourism by building a new airport and emphasizing that patients all over the world are familiar with English speaking Philipino doctors.

Dubai, has built a "Health City" to prevent the travel of middle-eastern tourists to Asia.

Apollo, India's largest private sector health group, had 37 hospitals in 2004 and hospital partnerships in Kuwait, Sri Lanka and Nigeria.

Inputs of medical tourism industry which provide great contribution to countries are depicted by Figure 4.

Figure 4: Inputs for Medical Tourism

(Gonzales, Brenzel, Sancho, 2001: 46)

2.4. Health Tourism and Sectoral Growth

When sectoral transivity is taken into consideration, undoubtedly the health tourism will bring with its sector specific legal advisory services differentiation in jurisprudence infrastructure and lead to advancements in profession. Another complementary sector which will also develop and grow is the insurance sector. Accelaration of the utilization of sectoral electronic equipment and related R&D points to an important potential market.

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Health Tourism: 1900s to 1997

During this time period, USA and Europe became the world health care centers in addition to being commercial and industrial centers. Travel for health care to these countries were considered to be an option only for the very wealthy. In 1933, American Board of Medical Specialties (ABMS) was established and became an umberalla institution for Medical Boards in the USA. ABMS developed educational and professional policies and these became the basis for worldwide standards. In 1958, Union of European Medical Specialists (UEMS) was formed. UEMS consisted of different unions from European member states. In 1960s, when the New Age movement began in the USA, India became an important spiritual destination. The "flower child" movement which attracted the US and British society progressed and became a new health tourism with the discovery of yoga and ayurveda.

During the 1980s and 1990s, US patients began preferring Central American countries for treatments such as dentistry. While initially US doctors were terrified with the idea of receiving treatment in foreign hospitals, Cuba became an attractive health tourism location for eye, heart and cosmetic surgery.

In the international arena, JCI Accreditation Institution was established in 1994 to monitor and investigate increasing number of hospitals offering health services internationally to determine whether they were compliant with international standards. Hospital which were accredited began receiving patients from all over the world. JCI accreditation was a source of assurance for the patients.

Health Tourism: 1997 to 2006

Asian economic crisis of 1997 and devaluation of Asian currencies caused governments to pay special attention to tourism. Comprehensive advertising campaigns were initiated for the development of health tourism. These efforts paid off. Thailand became a plastic surgery center within a short period with its low cost compared to western countries. Health tourism stops in Thailand, Singapore and India became legitimate with the JCI accreditations. Other Southeastern Asia and Latin American countries are continuing to be health service stops through JCI accreditation and partnerships with leading US based health corporations.

Health Tourism: 2007 and Later

In 2007, departing US health tourist numbers reached 300 thousand, highest recorded to date. In 2010, this number was 1 million. In 2008, several health and insurance corporations in the USA began considering the use of outsourcing. They began offering to their membership treatment opportunities

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abroad for non-emergency care and surgery (www.health-tourism.com/medical-tourism/history).

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3 ANALYSIS OF HEALTH TOURISM SECTOR IN TURKEY AND ANKARA

In the field of health tourism, Turkeymade significant progress especially during the past 20 years and began competing with countries such as India, Maleysia, Thailand and Hungary. In recent years, with State supported investments and advancements in contemporary technologies, national health care services quality has improved in İstanbul, Ankara and İzmir. Investments made in personnel and hospitals played a major role in the developments seen in health tourism of Turkey In this context, private sector investments in health care since the second half of 1980s have also played a very signficant role.

It has been established that 74 thousand health tourists in 2008, 94 thousand in 2009, 110 thousand in 2010 arrived in Turkey Turkey’s total tourism revenue for 2012 is US$30 billion and the number of tourists received is nearly 30 million. In 2010, it was US$21 billion and 28.632.204 persons respectively. Among the reasons for tourists were 58.5% entertainment, 6.4% culture, 11.1% relative visits, 4.8% shopping. 64.58% of travel was by airlines, 29.08% by land. In 2009, there were 27.077.114, and in 2008, 26.336.677 visitors.

Health Tourism in Turkey, Accreditation and Surgery Prices

Today there are 47 health institutions in Turkey possessing Joint Commission International (JCI) accreditation considered to be the most important among the 5 systems in use around the World. This the highest number seen in world scale and corresponds to nearly 10% of all accredited hospitals in the world.

When compared with Turkey, India has 16, Thailan 11, Singapore 16, Brazil 23, Saudi Arabia has 33 JCI accredited hospitals. When a comparison of prices according to surgery types are made between the USA, Turkey, Ireland, Thailand, Singapore, India, Israel and Switzerland:

In the category of bypass surgeries, best priced operations in the range of US$11.375-15.000 are in Turkey.

In vertebrae fusion operations, Turkey is the most attractive country positioned after Taiwan with US$7.125.

In bone-marrow transplantations, Turkey shares first ranking with India within the price interval of US$ 40.000-70.000.

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It has been announced that US$8 billion private sector and government investment will be made in Turkey in 2015 in order to be able to serve 1 million visiting foreign patients.

3.1. Thermal Tourism in Turkey

One of the alternative tourism types, thermal tourism is a branch of tourism adopted and considered important in our country, and the attention paid to it develops continually. Due to its geographical poisition, Turkey has deep tectonic fault-lines, and possesses rich and unique mineral infrastructure. Poisitioned on Alpine-Orogenic mountain range and important geothermal belt, thermal waters available in more than 1500 hotsprings exhibit superior qualities to that of Europe in terms of flow-rates, temperatures, various physical and chemical characteristics. Consequently it is one of the world leading countries with extensive resources of thermal and rich content mineral drinking waters. With temperatures and flow-rates respectively in the range of 20-110oC and 20-500 lt/sec, and with its 1500 springs, Turkey is considered among the top seven countries in the world. Possessing world class potential in geothermal resources, Turkey is ranked first in Europe and third in terms of hotspring applications (T.R. Ministry of Culture and Tourism). According to the studies done, therapeutic springs in all geographical regions of the country are more than 2000. But only 1300 of these possess thermal resource characteristics. Only 102 springs were thermally analyzed and classified. For this reason, completion of the research of thermal resources confront us as a fairly important question concerning support of health tourism (İbret, 2007).

Figure 5 shows the map depicting major geothermal resources and wealth of the country in this filed.

Figure 5: Geothermal Resources Map of Turkey

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Thermal tourism offers an unequalled health tourism potential through its high mineralization content with therapeutic effect, in combination with our country's rich cultural heritage, nature and climatic characteristics. When considered in terms of thermal tourism, our country has the capacity to spread cost of integrated complexes to a full year for speedy cost recovery and ROI as well as effective competitiveness. High annual occupation rates at the complexes and due to it the positive contribution made to employment are some of the benefits of thermal tourism.

Thermal tourism is being supported by State authorities due to its advantages and prominence at the world stage. When the country is considered in general, there are four Thermal Culture and Tourism Protection and Development Regions (KTKGB) and 70 thermal tourism centers (TM).

Figure 6 depicts these centers.

Figure 6: Thermal Tourism Master Plan Regions

Some of the TMs are as follows:

Afyon, Sandıklı, Hüdai Thermal Tourism Center

Located in the Aegean Region, the center is 7km to the township of Sandıklı and 66km to the histroric city of Afyon. Water temperature is 70oC. Visited for rheumatismal ailments, painful syndromes, heart and cardiovascular diseases, arthrolithic joints, nerve and muscle exhaustion, neurological diseases and women's ailment treatment.

Afyon, Gazlıgöl Thermal Tourism Center

Located on Afyon-Eskişehir highway and railroad route and is 22km to the city of Afyon. Water temperature 40-71oC. Indicated to be helpful in treatment of rheumatismal, heart and cardiovascular, kidneys and urological, liver and gall-bladder, digestive system, metabolism irregularities, bone and arthritis, and dermotological ailments.

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Afyon, Ömer and Gecek Thermal Tourism Center

Located on the Afyon-Kütahya highway, 15km to Afyon. Water temperature is 51-98oC. Indicated to be helpful in treatment of rheumatismal, heart and cardiovascular, dermatological, kidneys and urological, liver and gall-bladder, digestive system, dietary irregularities, bone and arthritis, neurological, women's ailments and dermotological ailments.

Ankara, Kızılcahamam Thermal Tourism Center

Located at Kızılcahamam township near the Capital City Ankara. Water temperature at the main spring source is 47oC. Drinking cure courses: Liver, gall-bladder, stomach, intestinal and metabolismic irregularities. Bath cure courses: Heart, cardiovascular irregularities and rheumatism.

Balıkesir, Gönen Thermal Tourism Center

Adjacent to the Gönen river in Gönen township of Balikesir. Water temperature is 52oC.

Drinking cure courses: Liver, extrahepatic bile ducts, kidney functions. Bath cure courses: rheumatism, bone fracture sequellae, painful and infected women's ailments, large intestine pains and spastic infections, arteriosclerosis, neurological and vascular complication sequellae and recuperation periods.

Bursa, Çekirge Thermal Tourism Center

Located in the Çekirge district of Bursa. Water temperature 47-78oC. Banyo Cures: Rheumatismal syndromes, other painful diesases of the skeletal motion, chronic infections and painful women's dieases, artery blockages. Composite drinking-bath cure courses: Liver, extrahepatic bile ducts, light diabetes, gout disease with exception of crisis periods, obesity exhibiting extreme fat accumulation in blood.

Bursa, İnegöl Oylat Thermal Tourism Center

27km south of İnegöl township near the historical city Bursa. Water temperature 40 oC. Indicated to be effective against overweight.

Çanakkale, Ezine, Kestanbol Thermal Tourism Center

15km to Ezine township of historical city Çanakkale. 2km to the Sea of Marmara. Water temperature at main spring source 67 oC, in mud 68 oC. Bath, mud-bath, inhaleation, sprinkling cure, indicated to be effective against infectious women's diseases, rheumatism, siatica, arthritis, and some types of bone tuberclosis.

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Denizli, Pamukkale Thermal Tourism Center

In the Aegean Region, 20km north of the city of Denizli and adjacent to ancient Hierapolis archeological ruins. Water temperature 33-35,5 oC.

Drinking curecourses: Digestive system, especially stomach, intestinal, liver, functional irregularities of extrahepatic bile ducts, gall bladder and chronic extrahepatic bile ducts infections, gall bladder stones, obesity, diabetes, and gout. Bath cure courses: Diseases ocncerning cardiovascular system, heart, brain and arterial ischaemic syndromes, arteriosclerosis, blood pressure fluctuations, bronchial asthma occurrences.

Eskişehir, Sarıcakaya, Sakar Thermal Tourism Center

Located in the Sarıcakaya township and is 33km to Eskişehir. Water temperature is 35 oC. Diabetes, obesity, goute, accumulations in blood, and is believed remove sugar and fat, and cause removal of excess uric acid, and prevent kidney stone size increase.

İzmir, Balçova Thermal Tourism Center(Agamemnon Thermal Complex)

25 km to the İzmir Adnan Menderes Airport, and 8km to historic city center. Cablecar service to pine forested Balçova hills where the complex is located creates attraction. Main spring and well water temperatures range between 45-140oC. Indication: Rheumatismal diseases, digestive system, eye diseases, metabolism irregularities, liver-gall bladder ailments, cardiovascular and heart diseases, neurological system diseases.

İzmir,Çeşme, Şifne Hotsprings and Mineral Drinking Waters:

5-7km east of Çeşme township of Izmir. Water temperature is 42 oC. Bath and mud cures are indicated to be effective on rheumatismal ailments, women's diseases, metabolismic irregularities, and drinking cures have laxative effects, and increases secretory functions of liver, gall baldder and pancreas.

Konya, Ilgın Thermal Tourism Center

Located 88 km from the historical city Konya in Ilgın township on 2nd km of Ilgın-Akşehir highway. Water temperature 42oC. Indication: Rheumatismal diseases, liver, extrahepatic bile ducts, metabolismic ailments.

Kütahya, Harlek(Ilıcaköy) Thermal Tourism Center

27km from Kütahya on the Kütahya-Eskişehir highway. Water temperature: 25,2 - 43 oC. Rheumatism, liver, extrahepatic bile ducts, and dermatology.

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Muğla, Köyceğiz, Sultaniye Thermal Tourism Center

Located on the western shore of Köyceğiz Lake near the historical city Muğla. Water temperature: 41,9 oC. Indication: rheumatism, dermatology, cardiovascular system, heart conditions, repiratory track, nerve system, kidneys, urology, women's diseases, metabolismic irregularities, and assist in recuperation periods.

Sivas, Kangal, Balıklı (with fish) Hotspring

17km northeast of Kangal township of historical city Sivas. Water temperature: 36 oC. Use: 3-5 glasses must be drank on empty stomach, 6-8 hours in the pool daily with intervals, no alcohol shall be consumed during cure, no medicine shall be applied to skin lesions. 21 day cure. Treats bodily wounds, skin lesions, eczema, psoriasis of skin, pustulates. Treatment is applied by extremely unique fish living in therapeutic mineral water and feeding on human body scabs.

Yalova Thermal Tourism Center:

11km west of Yalova located in a forested area. Water temperature: 55-60 oC.

Bath cure courses: Primarily rheumatismal ailments, painful diseases of skeletal mobility, post-abdomenal operation ailments, chronic infectious women's diseases, types of arterial blockages in the legs. Drinking and bath cure courses: Diabetes, goute, metabolismic irregularities such as obesity, removal of cholestral, lipid accumulations in blood, removal of uric acid by way of urinary track.

3.2. Health Tourism, Medical Tourism and Thermal Tourism in Ankara

When categorized according to cities, 17% (8 instititutions) of JCI accredited hospitals are in Ankara (see Figure 7). Additionally, Figure 8 shows that 8% of total medical tourism of Turkey is in Ankara.

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Figure 7. Accredited Hospitals in Turkey and Ankara (Source: Joint Commission International statistics)

[DD1]

Figure 8. Medical Tourism in Turkey and Ankara

With the help of increased service quality standards, Ankara can provide siginificant contribution on the route to becoming a health tourism center. As a consequence of Ankara stepping forefront in the health tourism sector, and with increased numbers of visitors nationally and internationally, the sector including medical tourism, thermal tourism/SPA-wellness, and aged/handicapped care can contribute to the economic and social development of the city, and make it an accessible competitive national and international tourism center.

Important hotsprings of the province are: Kızılcahamam-Sey, Ayaş, Ayaş Karakaya, Beypazarı-Dutlu-Tahtalı, Kapullu, Çubuk Melikşah and Haymana thermal mineral water facilities.

Ayaş Mineral Drinking Water and Hotspring

Temperature is 51oC. Known to have positive effect on upper-respiratory track ailments and lung diseases.

Ayaş Karakaya Hotspring

Hotspring temperature is 31°C. Chemical composition contains: bicarbonates, sodium, calcium, and carbondioxite. Also used as drinking water.

Çubuk Melikşah Hotspring

Located in Çubuk township 30km from Ankara. Water temperature is 31°C. Calcium, magnesium and bicarbonates are present in the water.

38%

29%8%

8%

7%3% 2% 2%2%1%

MEDİKAL TURİZM HASTA SAYILARININ İLK 10 İLE GÖRE DAĞILIMI

ANTALYA

İSTANBUL

KOCAELİ

ANKARA

MUĞLA

İZMİR

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Dutlu-Tahtalı Hotsprings and Mineral Drinking Water

Located in the township of Beypazarı. Springs are used for drinking water and as thermal therapy. Water temperature is 31-52°C. Hotspring water has chloride, sulphate, sodium, calcium, carbondioxite composition. Known to have positive effect on dermatological ailments, liver, gall bladder, pancreas, and arteriosclerosis.

Haymana Hotsprings

73 km from Ankara and in Haymana township. Water temperature 44.5°C. Composition: bicarbonates, calcium, sodium, magnezium and carbondioxite. Known to have positive effect on stomach, liver, pancreas, arteriosclerosis and lung ailments.

Kızılcahamam Hotsprings

Water temperature at the main source is 47°C, at the tributory 44°C, at the source of mineral drinking water 19.5 °C, at Acısu Hotspring source 34°C, Şey Bath source 43°C. Water, as a physical and chemical composition, belongs to the hyperthermal and hypotonic classification. Facilities are used for drinking water and bath. Drinking cure courses are effective on liver, gall bladder, stomach and intestinal, internal and external secretion colons, and metabolismic irregularities. Bath cure courses are effective on heart conditions, cardiovascular irregularities, and rheumotismal ailments. Complex are contains accomodation facilities.

Kızılcahamam Şey Bath Thermal Tourism Center

On the Kızılcahamam-Çerkeş road, 2km west of Güvem village, water temperature is 43°C. Chemical composition includes bicarbonates, sodium, calcium, carbondioxite and flourides. Thermal facility is used for drinking water and bath cure courses. Its positive effect on rheumotism, arthiritis of joints, stomach and intestines, cardiovascular system, neurologic ailments, liver, gall bladder, and dietary irregularities. Accomodations exist in the vicinity.

Every year, Turkey welcomes nearly 30 million tourists and earns a revenue in excess of US$30 billion. An importnat compenent of this general tourism is the health tourism. Health tourism in Turkey earned US$850 million in 2010 and is growing a rate of 35% annually. In addition to these positive data we also have certain problems. One of these is the inadequacies of legal infrastructure. Qualified work must be done in such areas.

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4 MODELS ON INFRASTRUCTURE OF HEALTH TOURISM FACILITIES IN COMPETITIVE COUNTRIES, INTERNATIONAL TOURIST ACQUISITION AND SERVICE PROVISION MODELS

4.1. World Models About Alternative Tourism and Health Tourism

When the tourism sector is viewed in general, it is observed that tourists also prefer health tourism options in addition to traditional vacation, rest, entertainment and culture tourisms. With the spread of hotspring visits among the European population in 18th century, it is possible to state that beginnings of the health tourism movement were lead by therapeutic thermal resources. In 19th century also there were touristic travel to distant colonies such as New Caledonia and tropical climates with the goal of healing (Smyth, 2005). It is also the primary objective of those travelling today to countries such as Kırgızistan (Schofield, 2004).

The alternative tourism variation health tourism has internal classifications such as climatism (clean air), thermalism (hotsprings) and uvalism (locale specific fruit and vegetable cure courses) (Akat&Ömer, 2000). But this study only concerns health and thermal tourisms.

Medical tourism, in its most general form, is defined as the touristic movement of travelling abroad for medical reasons due to high-cost of locally available treatment(www.healism.com). Similarly, Ross (2001) defines health tourism as a type of tourism in which people travel for reasons of health to a location other than their area of residence. In addition to low cost of treatment, most important factors in the development of this form of tourism are the advances of medical technology, low cost of transportation in such countries and internet marketing (Kılıç&Kurnaz, 2010).

Health tourism became an important sector with rapid rise in the number of people travelling abroad for the purpose of medical care or surgical intervention, and is showing fast growth around the world. In a relevant field study(Dr. Prem Jagyasi) made in health tourism, leading countries, annual numbers of patients and the revenue generated can be listed as in Table 1 (T.R. Ministry of Health, Medical Tourism Survey, 2011).

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Table 1: Prominent Countries in Medical Tourism

1. India

2. Thailand

3. Singapore

4. USA

5. Maleysia

6. Germany

7. Mexico

8. South Africa

9. Brazil

10. Costa Rica

11. Poland

12. Saudi Arabia

13. Switzerland

14. Argentina

15. United Arab Emirates

16. Turkey

17. P.R.China

18. Spain

19. England

20. Avustralia

21. Cuba

22. France

23. Panama

24. Phillippines

25. Belgium

26. West Indies

27. Hungary

28. Israel

29. Japan

30. Jordan

31. Moracco

32. New Zealand

33. South Korea

34. Taiwan

35. Tunusia

As can be seen in Table 1, Southeastern Asian countries are generally dominant in health tourism market. India in particular is a sectoral leader with its price advantage. However, high ranking of USA in the list demonstrates that people also prefer high quality treatment and care as well as high technology regardless of their high-cost. Common characteristics of the top three listed countries can be stated as follows:

High quality of health care and wellness services, Easy access destinations, Good technology, infrastructure and expertise indicators.

Continent of Asia is the most important area for medical tourism. Region attracts 1.3 million medical tourists annually. Scope of this activity has reached surprising dimensions in countries such as Thailand, Singapore, India, South Korea and Maleysia(İçöz, 2009). India is accepted as the leadere of medical tourisim and she has renewed her technologies, adopted western medical methods, and emphasized low cost and speedy care in advertisements in order to become the global center. Although the technology level was raised to

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western standards, and doctors are experienced and familiar with western procedures, labour costs are very low and insurance less expensive(Connel, 2006).

5 most health tourist receiving countries worldwide:

Panama

Brazil

Maleysia

Costa Rica

India

Countries sending most health tourists:

Underdeveloped countries(Sudan, Somalia, Afganistan, Libya, etc.)

Basic reason: Inadequate health services and insufficient personnel

Asian countries(Pakistan, Iraq, Syria, etc.)

Basic reason: Inadequate health services and insufficient personnel

USA, Europe

Basic reason: Health services very expensive and waiting patient lists are long.

Countries with high old-age population rate

Basic reason: High ratio of aged persons, insufficient personnel and high cost of care.

Some information concerning the health tourism systems/models of the four leading countries(India, Thailand, Singapore, USA) are presented below (T.R. Ministry of Health, Medical Tourism Research, 2011).

India's Health Tourism Model

Substantively assertive in the health tourism arean, India in recent years acquired advanced medical technologies and equipment, modern hospitals, and with well informed and experienced doctors and health personnel trained abroad, she is offering services in many specialist branches and continually raising the bar of service quality.

In addition to low price advantage, due to ease of access to treatment the patient is received in the operating room on the second day of arrival without any waiting period and treatment is commenced. Urban centers in the forefront

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of health tourism are Bombay, Pondicerry, Chennai, New Delhi, Bangalore and Ahmadabad.

Although "entry visa" is not required in India, in order to support and incentivise health tourism, patients arriving are given multiple-entry visas valid from 6 months to a year.

Thailand's Health Tourism Model

Thailand is among the most competitive and expanding in health tourism, and attracts high numbers of tourists from other Asian countries especially in the areas of cosmetic, organ transplantation, orthopedic, dental and cardiovascular treatments and surgical interventions. Private sector based health services, although deemed expensive by the locals, are considered fairly low by patients arriving from abroad and suitable prices top the list of preference reasons. Even so, it is not possible to claim that Thailand is low-cost in all types of treatment and surgical interventions. For example, in cosmetic surgery there isn't a big price gap between her and the USA.

Singapore's Health Tourism Model

Although a very small country in terms of territorial area, Singapore achieved the best health system in Asia. In recent years it has been able to attract health tourists measured in hundreds of thousands from China, Southern Asia and the Middle East in addition to those from its neighbours Indonesia and Maleysia. Furthermore, Singapore is seen as an attractive health tourism destination in the USA and many countries of Europe such as England.

Having received around 210.000 health tourists in 2002, offered health and treatment services to 410.000 in 2006. State of Singapore which pays extreme attention to health tourism and having made it a government policy aims a minimum of 1 million health tourists in 2012.

Additionally, the World Health Organization lists Singapore above USA and Canada in terms of health services quality offered by State and private hospitals.

USA's Health Tourism Model

While many uninsured or low-coverage insurance holder US citizens are preferring countries such as India or Singapore for health services, large numbers of people from abroad arrive in the US for the purpose of medical treatment. Altough a major drop in arriving tourist numbers was observed after September 11 events, today it seems to have reached pre-September 11 levels in arriving patients.

35% of patients travelling to USA for treatment originate from the Middle East which also includes Turkey. US health sector which adopted a double-edged

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policy toward foreign patients not only attracts health tourists to the USA but also delivers the service to foreigners by establishing health service infrastructures in other countries.

The USA which is defined as a country of extremities and opposites in the health services arena possesses nearly 45 million citizens with low income and/or insufficient insurance coverage who may be forced to seek halth services elsewhere even with the passage of a recent Obama health act bill. But due to high technology and quality care, in addition to decades of best reputation, USA continues to protect its attractiveness in terms of health tourism regardless of her high-costs.

4.2. World Status of Health Tourism

Health tourism, which is growing fast as a consequence of globalization, problems in national health systems(e.g., long waiting lists, rising costs, service quality deficiencies), consumer awareness and dynamics such as European Union (EU), is a concept which in general terms includes vacation and treatment elements. Today India is the leading country with greatest share in the health tourism. Annually, nearly 150.000 medical tourists visit India. An annual growth rate of 30% in Indian health tourism has ben recorded and its health tourism revenue is expected to be UK £1.2 billion in 2012. The basic reason for this popularity is foreseeing of this tourism potential, low prices and effective advertising. India's past as a British colony might also have a role in her poisitive recognition. India's recent economic and technological advances must also be considered in this context (Yıldırım, 2006).

Eastern European countries fast adapting to the capitalist world are beginning to get a significant share from the health tourism market especially due to low cost labour and EU membership advantages. A rising star Hungary, the first country considered by the Turks, has an annual revenue of US$2 million just from dental treatment. Belgium, a western EU country has a significant sectoral share especially in esthetic surgery and obesity treatment (Yıldırım, 2004). According to a survey by the French Le Figaro newspaper, Mid-EU, Asian and touristic countries of North Africa began forming a new tourism reserve in the fields of heart surgery, kidney transplants, dentistry and eye care (Le Figaro, 2006). According to the same survey, forerunners are India in heart surgery, Thailand in kidney transplants, Hungary and Poland in dentistry, Tunusia and Moracco in eye care. Surveys have showed that the cost of health services in the aforementioned countries are on average 40-70% cheaper than western EU countries. A teeth prothesis costing 4 thousand Euro in France can

26  

be had for 3 thousand Euro in North Africa. A lift surgery costing 6 thousand euro in France, costs less than 4 thousand Euro in Tunusia or Moracco. Teeth implantation costing upto 1500 Euro in France can be done for upto 600 Euro in Hungary (Le Figaro, 2006).

Whereas the citizens of England accept treatment abroad because of long waiting periods of State health services and high-cost of private sector services. But the French have adopted this type of tourism for health services such as dentistry not covered by their insurance organizations (Le Figaro, 2006).

Especially in Poland and Hungary at the forefront of dental care in particular, an increase in the number of private clinics offering services in English, French and German are recorded to be on the rise. EU membership of these two countries and the insurance compensations payable anywhere in EU are shown as the leading factor in medical tourism increase in Central EU countries. Tourism experts unite in the opinion that the increase in medical tourism will progress rapidly in the near future. For this reason it is anticipated that the EU will prepare a legal framework for medical tourism applicable in all EU countries (Hastane Dergisi; 2007).

International health service providers in Eastern Asia and Central EU countries draw attention as stars with rising medical tourism. India is a fine example in this regard and has advanced significantly in treatments of open heart surgery, cosmetic surgery, joint prothesis surgery and dental care. Many patients especially form the USA travel to Indian centers for treatment. It is a known fact that cost of health treatments in the US are the most expensive in the world. Unit costs of many types of surgery in India are 4-5 times cheaper compared to US, and in some treatments such as bone marrow transplants it is 7-8 times cheaper. This renders India very attractive to those US citizens who have insufficient funds for local treatment, or with inadequate or no insurance coverage. In 2006, 150 thousand foreigners travelled to India for treatment (CBC News; 2007).

In 2007, more than 300.000 Amercians have travelled to other countries for medical care and medical tourism was declared as health trend in the same year(http://health.msn.com, 2008, January 5).

Studies made on medical tourism show that the world health tourism market has grown fast since 2000 and became a very significant market. In 2005, 1.9 million people travelled for medical therapy creating a US$20 billion volume. By 2010 these numbers were expected to double and reach 4% of general world tourism. Similarly impressive figures are exhibited by some Asian countries. Acccording to World Tourism Organization(WTO) - 150,000 persons from western countries have received treatment India. According to data from

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McKinsey, India earned a revenue of €333 million at this sector in 2003 and this revenue is expected to be €3 billion in 2012 (Oxford Analytica, 2006).

A similar situation exists in Thailand which earned nearly €600 million with health tourists numbered between 600.000 and 1.000.000(http://www.turizmdebusabah.com, 2007, June 13). Medical tourism structures of some countries are summarized briefly in the table below:

Table 2. Health Tourism Structure of Various Countries (Xavier Institute of Management)

4.3. Global Health Tourism Patient Traffic

Figure 9 depicts some of the countries engaged in health tourism. Figure 10 depicts the stakeholders in medical tourism. Figuer 11 depicts the world health tourism traffic.

Country Number of patients

receiving treatment in 2003

Country of Origin Revenue (Million) Strengths

Thailand 600.000 USA, England $ 470 Esthetic surgery, organ transplantation, Dentistry

Jordan 126.000 Middle East $ 600 Organ transplantation, Infertility treatment, Cardiology

India 100.000 Middle East, Bangladesh, England, Developing countries

No data Cardiology, Orthopedics

Maleysia 85.000 USA, Japan, Developing Countries

$40 Esthetic Surgery

R. of South Africa 50.000 England, USA No data Esthetic surgery, Dentistry

Cuba unknown Latin America $ 25 Nyctotyphlosis, Eshtetic surgery

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Figure 9: Countries engaged in health tourism

Figure 10: Stakeholder examples in medical tourism

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Figure 11: Health tourism traffic in the world

(Source: Health Travel Technologies web site: www.healthtraveltechnologies.com)

4.4. Global Thermal Tourism

Continual increase of facilities categorized today as SPA&Wellness, hotsprings, mineral water cures, thermal complex, thermal cure course clinics, centers, hotels, rehabilitation, health and beauty resorts is the result of expanded interest and demand in this area.

17% of Europe's population at age 65 and over in early 2000s is expected to reach 20% in the year 2025. Especially those age 50 and over with high purchasing power, referred to as the 3rd Generation, and their desire for treatment or remaining vigourous with preventative medical practices form the basis of major emerging demand for high quality wellness centers. Aging EU population is creating further thermal treatment requirement. This demand is more prevalent especially in the Northern Europe and Scandinavian countries where rheumatismal ailments are seen.

Thermal tourism has become an important sector in Germany. 263 certified thermal centers in Germany has a total bed capacity of 750.000. Das Leuze Hotsprings and Recreation Complex in Stuttgart, Germany is visited by 8000 people per day during the summer season. Annual average is 3000 persons/day. Providing that doctor diagnostic report exists, Germany is one of the countries where hotspring therapies are covered by State or private sector insurance institutions in whole or in part. Very advanced hotspring centers were establihed in the Czech Republic and Slovakia during the recent years. These two countries have 60 therapeutic thermal centers and nearly 500.000 patients are treated annually. If a doctor's report exists, insurance companies pay the cost of treatment in whole or in part. Additionally, there are 104 thermal

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complexes in France, 128 in Spain, 360 in Italy. Russia has deep thermal culture and it is claimed that annually 8 million visits take place. Thermal tourism in Japan involves 100 million overnight stays annually at 1500 hotsprings. In Beppu, 1000 litre/sec geothermal source is being used for thermal tourism. In the US, at the State of Arkansas, a thermal complex with 55 thousand person capacity has been built, and in Hawai newly erected thermal complexes for tourism has commenced operations in order to spread general tourism to twelve months of the year (T.R. Ministry of Culture and Tourism).

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5 MEDICAL TOURISM SERVICES IN TURKEY

Medical tourism aims to provide medical options to comfort the patients and their families. In parallel to high level education and prosperity in more developed countries, health services offered are also much higher. In these countries, health needs of the aging population and the share of general health expenditure is increasing. Increased social security expenditures are pressuring the social security institutions. In order to overcome these difficulties, it is observed that social security and private sector institutions in the developed countries are entering into package aggreements with near-by countries offering quality health care services in order to reduce their costs.

Ever since our country began offering high quality health services competitively compatible with those of developed countries, therapy seeking tourists from all corners of the world have been arriving during the recent years. During the 1990s in particular, substantial public and private sector investments were made in health services. Subsequently, many private sector health institutions capable of competition at EU standards emerged in major urban centers. High cost of construction and operation of these health care facilities require exposure in foreign markets primarily for ROI. Furthermore, our country's geographical position and its qualified health care personnel are among the advantages of Turkey (Ministry of Tourism, 2007).

In our country, State Planning Organization attached to the Prime Ministry is responsible for the planning of tourism and health care, and their incentivisation. Ministry of Tourism establishes the regulations, provides guidance and supervision to various types of operations providing direct services to the sector. Ministry of Health has numerous responsibilities such as establishment of health facilities, development of health personnel and their appointments, supervision and control of various health care institutions providing public services.

Efforts in the area of health tourism are located in the development and investment plans conducted by the State Planning Organization (DPT) (Aksu, 2001: 788). DPT plans concerning the health tourism were in the last four 5-Year Plan periods (5th, 6th, 7th and 8th Five Year Plans).

5th Five Year Development Plan dealt with the general issue as " Turkey's natural history, archeological and cultural assets, winter and summer sports,

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hunting, festivals, health and youth tourism, and other tourism potential shall be utilized by ecologic balance protection, clean and healthy environment, and beautification"(DPT, 1984: 120).

6th Five Year Plan stated that “Sectoral incentive policies shall be provided to render winter, summer, hunting sports, festivals, health, youth, congresses and conventions, thermal, golf and 3rd generation tourisms attractive. Numbers of those providing direct or indirect services to the sector shall be raised and trained to sufficient levels and their knowhow and skills shall be improved. Quantity and quality of tourism infrastructure and superstructure shall be raised. Measures ensuring quality improvement and extension of activity season shall be taken. General public should be provided with most suitable and healthy vacation conditions”(DPT, 1989: 281- 282).

7th Five Year Plan contains the expression “In order to improve the seasonal and geographical distribution of tourism, in consideration of foreign consumer preferences and for creation of new potential opportunities, golfing, winter, mountain, plateau, thermal, health, yachting, caravans, cruises, congress and entertainment tourism development activities shall be continued. National tour operations shall be expanded, new sources of financing shall be formulated for advertising and marketing jointly with public and private sectors”(DPT, 1995: 164).

8th Five Year Plan states that “Tourism shall be further developed in consideration of changed consumer preferences, and measures for spreading tourism to an entire year in regions with potential but not previously dealt with sufficiently shall be taken. In order to improve the seasonal and geographical distribution of tourism, in consideration of foreign consumer preferences and for creation of new potential opportunities, golfing, winter, mountain, plateau, thermal, health, yachting, congress and ecotourism development guidance activities shall be continued.”(DPT, 2000: 167-168).

9th Five Year Plan (2007-2013) indicated health, technical infrastructure and energy as weaknesses of national tourism and stated that “2/3s of national bed capacity is confined to the shore lines for beach tourism. Investment priority must be given to differentiation of national tourism and its spread to 12 months in thermal and health tourism, culture tourism, conventions tourism, mountain and summer range tourism, winter tourism, 3rd generation and youth tourism, yachting and sea tourism” and “faith, health, education, language learning are useful forms of tourism and must be encouraged"(http://plan9.dpt.gov.tr).

As seen in DPT plans, Turkey emphasizes seasonal and geographical rearrangement of general tourism, and in order to create new potential areas in

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accordance with the changing preferences of foreign consumers, attaches importance to health (medical and thermal) tourism.

A department concerning health institutions has been formed within the Ministry of Health for development of medical tourism and exploiting Turkey's advantages. In the draft Report of National Tourism 2023 Strategy prepared by the Ministry of Tourism, health tourism has been examined as a high priority area.

According to a study made by the Ministry of Health, number of foreign arrivals for the purpose of treatment in private hospitals during the first ten months of 2004 is 39.404. Of these, while 26.198 received treatment as out-patient, 13.206 were in-patients. When those treated in the State hospitals are added, this number is estimated to be near 50.000. As seen in Table 3, according to the same study of the Health Ministry, most of the patients were from EU countries (Tengilimoğlu, 2005: 91).

Table 3. Distribution of Foreign Patients According to Countries of Origin (2004 arrivals for treatment in hospitals in Turkey)

It is not possible to claim a very significant foreign patient arrival traffic. There are efforts underway in this regard primarily among the Istanbul and Antalya hospitals but it has not yet been transformed into a mass movement. There are 200,000 health visitors to Turkey annually majority of which utilize hotsprings and thermal facilities. Recently there have been increases in surgical intervention arrivals such as hair transplantation, eye surgeries, and in vitro fertilization (An-Deva Health Group, 2004: 17).

In 2004, 150.000 of tourists in Antalya applied to health institutions for various reasons and either themselves or their insurance companies paid a total

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of 50 million Euros (Çömez, 2005: 88). This figure is a good example and indication of revenues that could be earned from medical tourism.

It is assumed that with full membership of Turkey in EU, there will a rise in the numbers of patients arriving.

Turkey is not utilizing its health tourism potential effectively. Stated in general terms, three fundamental elements are required for actualization of medical tourism effectively and productively. Presence of these three elements, their cohesion and operation enables effective use of the existing potential. First of these elements is touristic assets(climate, nature, history, accomodation, quality hospitality services, etc.), second is the availability of health services infrastructure(hospitals, personnel, technology, specialty expertise, proper pricing, therapeutic waters, etc.) and third is the existence of professional organizations which will unify potential clientele with the national health tourism sector.

In recent years a movement has begun in the Turkish medical tourism sector which wishes to benefit from patients potential in EU countries, especially after EU membership candidacy and ascension negotiations commencement agreement of October 3rd, 2005. But it may also be said that the sector is not yet sufficiently organized to effectively benefit from this existing potential. Most profound reason is the inadequate availability of the aforementioned third element. Furthermore reliable statistical data on the health sector is not fully available(in which specialty areas Turkey has advanced experience, how many hospitals are ISO certified, comparative data concerning the health sector vis-a-vis the world?). Medical tourists come to Turkey mainly from EU countries such as Germany and Holland where Turkish populations are concentrated and few existing intermediary professional organizations are positioned in these countries.

In England, considered to be a high potential market, there is only one company (Travel to Cure) for the purpose of medical tourism and national health institutions do not seem to have fully penetrated this market yet. Most likely factor in this case appear to be the small Turkish population in this country and unavailability of sufficient entrepreneurs capable of assuming this responsibility. Inadequacy of the organizing sub-sector has led some hospitals to be involved with the travel organization and tourism aspects. But these aspects require different professional expertise and it can be said that full success has evaded them.

In EU, which is seen by Turkey as a major potential client of medical tourism, the practice of medical tourism may be given under three main headings. These are, under EU statutes, free movement of citizens with the EU territory,

35  

secondly flow of patients within the scope of bilateral agreements, and thirdly attempts of individuals who wish to benefit from medical tourism but are not covered by the social security system of their country of origin and/or wishing to pay for treatment services through private insurance or private funds. One point of interest which should be noted here is that although patients have free movement privileges in EU, it is not possible to categorically state that this right is being used extensively. Basic reasons for this may be said to be language barrier, lack of information regarding health services offered elsewhere, differences in health systems, bureaucracy, cultural differences, cost of time and travel, unavailability of professional intermediary services, etc. Most important is the unavailability of assurance providing reference information. In short, lack of professional intermediaries between patients and health service providers, and ineffective use of those existing. Also, another negative effect is the clientelle whom were made unhappy by amateur intermediaries. Rectification of the damage caused to this developing sector by non-professional intermediary persons or organizations is going to be very time consuming and expensive. Each such blow to the not-so-positive image of Turkey is going to severely impact this important sector. What is clearly understandable from this is that proper presentation of the modern health institutions and their services by the Government, relevant organizations and citizens living abroad are of highest importance.

However small, Turkey is currently getting a share from the world health tourism market(primarily in hotsprings, esthetic and eye specialties). But regretfully highly reliable data on the monetary size of this share is not available. It is known that health institutions and doctors from Holland, Germany and Switzerland have established collaboration with private hospitals in Turkey during the past year.

As elements of competitiveness of Turkey in the area of medical tourism, it is possible to list the developed infrastructures of hospitals and their high quality medical technology, education and experience level of physicians and health-care service personnel at EU standards, price advantages, unequalled natural and historical wealth, suitable climate, high quality tourism facilities and operations, and world renown Turkish hospitality. In contrast, Turkey also has weaknesses as indicated above, and not-so-positive image in countries such as France, Belgium and England is an obstacle.

Increasing limitations on the ability of Eurpoean health insurances to compensate treatment expenditures have caused certain medical interventions such as dental diseases, esthetic surgeries, hair transplants or newly developed sight defects to be classified as non-essential, and some of these are either not

36  

paid at all or only partially. Due to this reason, for patients seeking such treatments, countries such as Turkey with hospitals and clinics equipped with the latest technologies and world class physicians offering comparatively low-cost services are excellent alternatives to expensive EU practices (Turizm Gazzette; 2007).

Subsequent to private hospitals' import of latest medical technologies to Turkey, and improvement of operating room and intensive care conditions of State and University hospitals in major urban centers, patients from Europe and Middle East began arriving in Turkey. Some of the efforts of medical institutions in the area of medical tourism as reported by the media are briefly as follows:

Memorial Hospital has entered into agreements in 2005 with selected health institutions from some countries and commenced a process whereby patients receive initial phase care at these selected institutions and second phase in the Memorial hospital. Preferred mostly by patients from Holland and Germany, the hospital is utilized mostly during summer season especially in the specialties such as cardiovascular surgery, in vitro fertilization and orthopedics.

Acıbadem Health Group providing medical tourism services, in the first eight months of 2004 provided care to 1,280 foreign patients through foreign insurance corporations and intermediaries, and to 825 through small companies. Patients mostly received sight defect, plastic and esthetic surgeries and dental treatments. While most of the patients arrived from countries such as Germany, Holland, Belgium, Switzerland and England where many Turkish citizens live, patients also arrived from countries such as Balkan countries, Ukraine, Azerbeyjan, Turkic Republics, Israel and Middle East (Hastane Journal, 2007).

In the area of dental disease medical tourism, the Dentistanbul Hospital is making concentrated efforts. 25% of the applicants to Dentistanbul Hospital are foreign arrivees, and the Hospital has prepared informative brochures in English, German and Russian targeting Mid-Europe and Russia(Hastane Journal, 2007).

American Hospital welcomes 35 in-patients monthly from the USA, England, Holland, Balkan Countries and Turkic Republics, and treats 30 out-patients. Hospital cooperates with various foreign medical faculties and hospitals, organizes conferences and symposiums, and collaborates with leading European insurance corporations in the area of medical tourism (Turizm Gazetesi; 2007)

Siyami Ersek Chest Heart Arterial Surgery Hospital receives a large number of patients from Europe due to its superior health service. Through the protocol

37  

signed between Kosova and Turkey, 1200 heart patients are treated at the Hospital. First 67 heart patients were treated by 2004. In 2003, 400 patients containing visitors from Azerbeyjan, Turkish Republic of Northern Cyprus, Macedonia and Albania were healed at this hospital (Zaman Gazetesi; 2006).

World Eye Hospital plans to conduct nearly 40 thousand cataract and laser eye surgery, and has selected Germany, Holland, Switzerland, Belgium and Saudi Arabia as target markets. In order to meet this goal, they have opened clinics attached to the Hospital in various cities around the world led by Amsterdam, Berlin and Munich. In its internet web site their services in eye health are presented in three languages, namely Turkish, English adn German. For foreign patients there are places of worship in the Hospital for muslims, christians and jews. Hospital provides services in different areas such as retina diseases, diplopia and cataract surgery.

While the Anatolian Health Center established in collaboration with Johns Hopkins aims to be the medical tourism focal point in cancer and women's diseases, International Hospital which has been providing treatment to Japanese patients for the last 12 years is now providing esthetic surgery, heart arterial surgery, cardiology, in vitro fertilization and pediatric diseases services to patients arriving from countries such as Turkic Republics, Albania, Romania, Bulgaria, and Denmark (Tercüman Gazetesi; 2007).

Among the fields expected to be in the forefront in near future are disabled care, esthetic and plastic surgery, cosmetic surgeries not covered by insurance companies, dental treatments, eye surgeries, infertility, cancer treatment, diabetes, asthma, kidney diseases and dialysis (An-Deva Health Group, 2004: 21).

According to the Zaman Gazette, a total of 200 thousand medical tourists arrive in Turkey from many countries. While some prefer the hotsprings, others prefer private hospitals for eye surgery, hair transplants and esthetic surgeries. Among the esthetic surgeries, most frequent procedures are nose reshaping, skin stretching, acne trace removals, and liposuction. Turks living in Germany, Holland and France prefer Turkey for treatment but are not well informed as to where they can get the best service for the required treatment. Some efforts have been initiated to encourage Turks living abroad to receive treatment in their own country. Citizens of many countries are required to obtain entry visas. In order to develop medical tourism, visa regime must be eliminated or rendered simple, and these are included in the plans (Zaman Gazetesi; 2007).

Due to the increase in medical tourism traffic, the relationships between the foreign insurance companies and health institutions in Turkey have expanded. The understanding of trust which is between Insurer and the insured must also

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be built between the patient and hospital, as well as patient and the insurance company.

Nearly all of the tourists arriving for vacation in Turkey are insured. Foreign patients either obtain special insurance policies to complement their existing policies or purchase travel insurance to benefit from the private hospitals (An-Deva Health Group, 2004:22,24).

When Turkey’s strengths and weaknesses in the medical tourism market, and the opportunities and risks are better known, it is thought that what needs to be done for larger share in medical tourism market will be seen more clearly.

Figure 12 shows the distribution of health tourists in years 2008, 2009, 2010 and 2012.

Figure 12. Distribution of health tourist arrivals toTurkey.

As seen in Figure 13 below, health tourist arrivals in private and State sectors exhibit a rising trend.

Countries sending patients to Turkey may be examined in four main claasifications (Genç, 2007):

Countries possessing large Turkish communities (Germany, Holland, Belgium, etc.)

Developing countries with limited services due to lack of infrastructure or physicians (Balkan Countries, Central Asian Turkic Republics)

Countries with expensive health services and where patients demand services not covered by insurance (USA, Germany)

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

2008 2009 2010 2012

Private State

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Countries with long waiting lists due to imbalance in Supply-Demand (England, Holland,Canada)

Figure 13. Specialties for which health tourists arrived at Turkey in 2009 and percentage distributions.

5.1. Competitors of Turkey in Medical Tourism

In the first instance, most significant markets for Turkey are the surgeries (eye, esthetic, dental, etc.) compensated by patients' own resources. In this respect, Turkey has many competitors. Most important of these are France, Belgium, Norway, Bulgaria, Letonia, Czech Republic, Hungary, Slovakia, Malta and Southern Cyprus.

Especially Belgium, due to its proximity to England and its extensive infrastructure, attracts many patients. In the final analysis, when the marketabilities of Turkey and Belgium are compared in terms of "image", it can be said that Turkey remains in the background (Özsoy, 2007).

In addition to the above, there are competitors in the Eastern and Far Eastern countries. India, maleysia, Singapore and Thailand are the leaders (Garcia& Besinga, 2006).

Excluding countries such as India which targets UK£1.2 billion in medical tourism for 2012, Bulgaria is shown among the most important competitors of Turkey. Bulgaria with health service costs as low as Turkey has the advantage of being an EU member (Kurşun, 2007; Özsoy, 2007).

0

10

20

30

40

50

60

70

80

90

100

Göz Diş Ortopedi Kardiy oloji Onkoloji Plastik

Cer.

Bey in Cer.

KAMU

ÖZEL

40  

Table 4. Position of Turkey In Correlation Made According to Annual Patient Numbers

5.2. 2023 Vision of Turkey

Number of Patients : 1.000.000

Total Revenue : US$ 20 Billion

Strong Aspects of Turkey in Medical Tourism

In comparison to some countries health services in Turkey are cheaper. In other words there is a price advantage.

Bed capacities of Hospitals and quality of physicians are above average.

Turkey has close proximity to Europe with aging population and Middle Eastern countries with insufficient medical capabilities.

Turkey has integration with western countries and as such it is able to provide services to patients from the West and Islamic countries.

There are sufficient numbers of bilingual personnel in the hospitals.

Especially, bed capacities, physical and technological infrastructures, and quality of physicians at private and university research hospitals are more than adequate.

Weaknesses of Turkey in Medical Tourism

- Health personnel and hospital administrators are not sufficiently well informed on EU health statutes and Patient's Rights.

- Publicity is inadequate.

- Negative image exists.

- Poor coordination with foreign insurance corporations.

- Not enough accredited hospitals.

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- Insufficent attention is paid to marketing strategies and marketing research.

- Wrong pricing practices.

- Inadequate coordination between the Ministries and sectors (Tengilimoğlu, 2005).

- Physical and technological infrastructures of State hospitals require improvements.

5.3. Requirements for the Development of Medical Tourism in Turkey

Health institutions targeting medical tourism must first obtain international accreditation. This is imperative since patients are expected from more advanced countries. Today, with respect to accreditation, JCI (Joint Commission International) based in the USA is considered to be the most reputable. JCI equivalent in EU is the EFQM. While both will be very useful, JCI accreditation may mean easier international patient flow. Possession of accreditation standards also increases treatment success.

Secondly, in order to guarantee a certain amount of patient potential, health institutions must be involved in a wide international insurance network as well as collaboration. One of the most important criteria is the possession of an international patient relationships department within the health institution. It is necessary to be involved with all needs of the patient including completion of medical and other forms, to communicate with foreign centers which treated the patient previously, to process insurance transactions, in short, it is imperative to make the patient feel at ease and at home.

Another imperative for reputation in medical tourism is recognition. Hospitals planning to offer international health services must develop programs for foreign recognition and reputation. It is necessary to demonstrate to the public of developed countries that many hospitals in Turkey and the level of services provided are more advanced than many countries in EU and the World. Opening representative offices in countries from which large patient groups are expected and entering into collaboration and cooperation agreements with first stage health institutions in these countries are yet another required dimension. It is also considered that organization of fairs, conferences and/or participation in such, international bilateral cooperation agreements, investment partnerships will raise the awareness and demand level among the public of EU, Middle East and Caucuses (An-Deva Health Group, 2004).

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With respect to recognition and publicity, important responsibilities and duties fall upon primarily to the Ministry of Health, Ministry of Tourism and NGOs. Because, medical toursim has a world wide volume of nearly US$100 billion and Turkey is unable to obtain not even 1% of this. While the Ministry of Health continue investments and allocations for the development of medical tourism, private sector should continue its investments. One of the parties in the medical tourism is the travel agencies which must collaborate with hospitals.

It is imperative to plan in the best possible way all manner of accomodations and activties for the duration of stay of patients in Turkey. It is necessary to raise client satisfaction to the highest possible level from the moment of arrival at the airport all the way to the particular attention to details such as cultural sensitivities and food choices (Hospital Journal; 2007).

An-Deva Health Group (2004) lists the planning and infrastructure efforts required for the development of medical tourism in Turkey as follows:

-Medical tourism must be given priority in the policies of both Health and Tourism Ministries.

-A department concerned with medical tourism must be formed in both Ministries.

-Target patient groups and countries must be identified, Ministry of Tourism must establish medical tourism representations in targeted countries, and initiate "recognition and publicity" efforts.

-Coordination with foreign insurance institutions must be achieved and informative publicity conferences organized.

-Hospitals to be engaged in medical tourism must be identified and certified. In-service training and controls of certified hospitals must be made.

-University hospitals must be more actively involved in the efforts of medical tourism.

-Patients' Rights and ethical principles must be at the forefront of the services provided.

-Cooperation must be established between the Ministry of Transport, Ministry of Health, Local Administrations, Tour Operators, Airlines and Airport Operators as well as other related sectors.

-In order to attain greater competitive strength, tax rates should be lowered to a reasonable level.

-Changes in the statutes concerning foreign State Insured must be made.

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-Statutes concerning the use of university and private hospitals by the arriving State Insured should be completed.

-Consultancy firms should be established for the organization of services to be received by the foreign patients and supporting companies should be made active.

-Turkish citizens living in Europe should be the forerunners of medical tourism movement and their treatment should be the initial target.

-Package programs to be offered to foreign patients should have varieties. In addition to the health treatment offered in the package, there should be activities of transportation, sea tours, hotspring treatments, skiing, nature hikes, historical site visits, and cultural events.

-For the establishment of country branding in medical tourism, publicities should be made with government support (An-Deva Health Group, 2004).

Ministry of Culture and Tourism has emphasized the requirement for establishment of health tourism standards and listed these standards:

• Health service with ethical values,

• Health service easily accessible physically and economically,

. Cultural communication between those requiring health service and service providers,

• Physical standards(suitability to health, transport and infrastructure services, environmental factors)

• Sufficient medical technology,

• International medical technologies,

• Internationally shared treatment protocoles,

• Sufficient information technologies,

• Transportation and transfer standards,

• Personnel standards

• Utilization of health insurance(Turizm Bakanlığı; 2007).

In order to reach a certain level in health tourism:

• Closer relationships and collaboration between social security institutions in Europe and national State/Private sector health organizations,

• Improvement of the overall quality of health service facilities,

• Publicity of Turkish health sector,

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• In addition to health services, offering of other touristic options (Ministry of Tourism; 2007).

For development of the medical tourism which is a component of international tourism which contributes in various ways to the national economy and gaining of a share from the market by hospitals desiring to focus on medical toursim, the target markets must be carefully chosen, marketing strategies of competitiors must be reviewed and marketing strategies with differentiating competitive advantages should be developed. Hospitals should have professional public relations and marketing managers for accreditation by international organizations and accessing foreign markets. Furthermore, they must give priority to employment of bilingual personnel and conduct publicity efforts among the insurance institutions of targeted countries. In recent years it seen that some hospitals in Turkey and the State are paying attention to this subject but not at the desired level. Responsibility for publicity should not rest only with the hospitals or their associations, but the necessary support should be provided by the Ministries of Health and Tourism, Tourism and Travel Agencies and their associations. In terms of technical and clinical infrastructure suitable for medical tourism, it can be stated that State, Private and University hospitals are adequate. But interms of paramedic and other support personnel it may be stated that foreign language skills are insufficient (Yalçın, 2006).

According to the results of a thesis titled "Requirement of Infrastructure Formation in Turkey for Medical Tourism and Study Concerning Health Institutions" done at the Gazi University, some of the findings indicate that State hospitals are more inadequate when compared to the private and university hospitals in terms of physical and technology infrastructure (Yalçın, 2006). Additionally, only 20.1% of the State hospitals possess a department concerned with medical tourism as compared to 52.1% of private hospitals. State hospitals have less (35,60%) bilingual personnel as compared to the private (65,30%) and university hospitals (75,00%). In the hospitals, bilingualism alone is not sufficient, all the signs and notices in the buildings, booklets and brochures, other published regulations must be in multiple languages, food offered must be fit to their cultural taste and beliefs. In the same study mentioned above, while 50.4% of private hospitals had positioned the in-building warning/directing notices in a way understandable by foreign patients, only 32.9% of State hospitals paid attention to it. While 42.1% of private hospitals provide faith personnel and food suited to different beliefs, only 10.1% of State hospitals are able to offer the same to their foreign patients. For effective communication with foreign patients, 35.5% of private hospitals have translators/interpreters on contract as compared to 0.7% of State hospitals. Similarly, State hospitals have less published and accessible informative

45  

publicity, and are engaged less with enterprises such travel agencies or tour operators (Tengilimoğlu, 2007).

While health services publicity in the USA is conditionally possible, in our country it is illegal. But today health corporations do use media tools such as newspapers, journals, private sector TV and radios, even billboards(Usta, 2000). This publicity made nationally must also be used international markets.

According to the specialists in the field, since we will be unable to attract patients by way of full membership prior to entry into EU, we must target the Turkic republics. We are only able to receive European patients whose coverage is not provided by health insurances. Additionally, wide unavailability of world class health services in neighbouring countries such as Iran, Iraq, Syria, Bulgaria, Romania and Azerbeyjan is our advantage. We are also nearer to the European patients in comparison to the Far Eastern and other Asian countries. Long flights are not desirable for patients travelling for health reasons. The high risk of contagious diseases in the Far Eastern and other Asian countries renders Turkey more attractive (Hastane Journal; 2007).

The five steps which must be followed for the development of medical tourism have been listed by Lengyel&Otvos (2003) as follows:

Initially medical tourism should be done regionally. Hospitals intending to accept foreign patients should obtain

accreditation. Bilateral communication should be developed among countries. A shared common information system should be formed between

hospitals. Treatment directives conforming to EU standards should be formed and

widely applied.

What needs to be done by the Government for development of medical tourism is as follows:

Ministries of Tourism and Health must be in cooperation. Legal aspects of medical tourism should be taken into consideration and

patients should not be victimized. The health equipment imported for the elimination of technology gap

should be standardized. The State should establish private-public sector partnerships among the

health institutions. For the provision of world-class health service and easing of foreign

patient access to health insurance companies, State must play a balancing role (Xavier Institute of Management; 2006).

For development of medical tourism, patients and those establishing policies for hospitals, insurance companies and

46  

government must be motivated. But what's important is not the creation of localized or personal motivation, rather globalized motivation. After the creation of this motivation, it is necessary to train the personnel (Jarlegand, 2003).

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6 STATUTORY ANALYSIS OF INSTITUTIONS INTENDING HEALTH TOURISM SERVICE IN TURKEY

6.1. Legal Framework for Health Tourism in Turkey

The Health Tourism Department has been established for overall focused supervision of the health tourism services in Turkey with the March 31, 2010 decision (approval 18529) of the General Directorate of Fundamental Health Services.

Responsible for activities concerning Health Tourism within the organization of Fundamental Health Services General Directorate, the Department of Health Tourism has been mandated to form the following divisions:

International coordination, Medical Tourism, Thermal Tourism Spa-Wellness, Advanced age and handicapped tourism

Many changes have been made in the statutes during 2011. In particular, incentives for health tourism publicity have been given priority, and carrying out and organization of health tourism, establishment of regulations for the development of health tourism applications, and coordination with related organizations have been given to the Ministry of Health with Cabinet Decision 663 with the Force of Law(KHK). The organizational diagram of Department of Health Tourism is as depicted in Figure 14.

48  

Figure 14. Health Tourism Directorate Organizational Diagram

Advisory boards for specific areas, including the Health Tourism Advisory Board, and commissions are going to be formed under the Health Policies Council established within the framework of New Organizational Law determined by KHK 633. Furthermore, working rights in Turkey for foreign physicians and nurses have been provided, and certain regulations/arrangements have been made for the Rights of claimant local and foreign patients who might encounter improper practices during their treatments. Additonally free-zones have been provided for health tourism and services to be provided in these areas have been made subject to Regulations.

6.2. Statutes related to EU

EU statutes (Rome Agreement) is based primarily on free movement within Europe. Free movement has four pillars: Movement of people, goods, services and capital freely. These four free movements can only be limited due to public security and health. When considered within this framework, one of the practical areas within people's free travel right is the movement right of

Minister

Under

Secretary

Deputy U. Secretary

Health Services General Directorate 

Health Tourism Directorate

Tourist Healthcare Unit

Advanced Age and Handicapped Unit

Medical Tourism Unit

Thermal Tourism SPA‐WELNESS Unit

49  

patients. Initially, patients right for unimpeded travel in Europe was regulated with charters numbered 1408/71 and 574/72, and consisted of three programs:

Program with serial number “E111” was to be used by EU citizens who unexpectedly required emergency care while visiting another EU member country.

Program “E112” was used for receiving planned health services from another member country(with the condition of obtaining a permit). And, program “E106” concerned those who crossed borders due to their jobs.

But, as of June 1, 2004, the "E111" form was replaced with "European Health Insurance Card". This card is required for people of European Economic Zone (EU, Norway, Iceland and Liechtenstein) and Swiss citizens who travel for puposes of business or leisure but might require medical services at the country of visit.

However, in addition to the legal framework providing cross border health services in EU, a new situation has arisen initially in 1998 and latter years with the decisions of European Court of Justice (ECJ). This situation can be seen as the framework of actual practice formed as a consequence of ECJ decisions, and its basis is non-obstructability of free movement which is a constitutional characteristic of EU. When considered in this respect, it seems Turkey will not be able to benefit from the health tourism opportunity arising from the free movement of patients enabled by EU statutes. There are two basic reasons for this: Firstly, Turkey is not yet a EU member state. Secondly, free movement rights are not widely exercised by patients. National Health Service (NHS) is known to forward patienst abroad or provide permits to those who do not wish to wait but NHS limits it with flight time. The destination country of the patient must be at a distance less than 3 hours of flight. For this reason, collaboration with NHS seems improbable. However, Turkey has a high potential for obtaining significant share in the other two medical tourism practices. Obtaining this share depends on meeting several conditions: State should facilitate and provide supports(investment incentives for the private sector, publicity, visa simplifications, etc.), and the entire health sector led by private sector should organize agressive publicity campaigns. Third and perhaps most importantly, it must collaborate with professional intermediary organizations (Yıldırım, 2004).

6.3. Fundamental Objectives of Thermal Tourism Based on Statutes in Turkey

Within the context of "Thermal Tourism Cities Project" initiated by the Ministry of Health for the purpose of improving Health and Thermal Tourism,

50  

new areas with geothermal potentials have been identified. In this respect, determination of geothermal potential, establishment of infrastructure opportunities and its correlation with alternative tourism, development of strategy with thermal objectives, and provision of environmental arrangements are done by Ministry of Health as service procurement out-sourcing agreements through General Directorate for Mineral Technical Exploration (MTA) and Development Bank of Turkey.

According to the regional map of Thermal Tourism Cities, there are seven basic areas. These thermal areas are:

1) Southern Marmara (Çanakkale, Balıkesir, Yalova)

2) Central Southwest (Afyonkarahisar, Kütahya, Uşak, Eskişehir, Ankara)

3) Southern Agean (İzmir, Manisa, Aydın, Denizli)

4) Central Anatolia (Yozgat, Kırşehir, Nevşehir, Niğde)

5) Central Northeastern Anatolia (Amasya, Sivas, Tokat, Erzincan)

6) Eastern Marmara (Bilecik, Kocaeli)

7) Western Blacksea (Bolu, Düzce, Sakarya)

Each one of these areas are targeted for development as destination centers, and facilities led by thermal complexes are going to be associated with various natural, cultural assets and sports. Within these areas, those identified as geothermal focused "Tourism Centers" and/or "Culture and Tourism Protection and Development Region" are going to be realized within a short period with increased funding.

In this connection, within thermal tourism, the objectives set are:

In the short-term, initiation of preliminary efforts without delay, formation of 250 thousand bed capacity, selection of pilot areas, and beginning pilot facilities in geothermal regions.

In the mid-term, completion of development and revision thermal toursim centers plans approved by the Ministry of Health, commencement of 200 thousand bed capacity facilities' operations, and spread of efforts initiated in pilot provinces to the entire country.

In the long-term, making Turkey the leading thermal tourism destination in Europe, attracting 15 million thermal tourists, and creation of 500 thousand operations concerning thermal tourism.

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7 WORKSHOP REPORT AND ASSESSMENT

In the Thermal Complex Feasibility Study Workshop held on 26 June 2012 within the context of Alternative Tourism Initiative Project, information was provided to the participants, their ideas with respect to alternative tourism in Ankara and its environs were sought, and their views with respect to the region were recorded. Questions and responses given in general were as follows:

1. Place of Ankara region in health tourism?

Resources present and potential, weak aspects of Ankara, obstacles ahead of health tourism?

Responses

• The reality of Aydos Mountain in the Çubuk area should be noted.

• Combination of health and nature tourism will contribute to the region.

• In the previous years chest diseases hospital was decided to be in Çubuk. But later it was repositioned in Ankara. A senatorium hospital must be erected near the forest. In this regard we expect Yıldırım Beyazıt University (YBU) to establish a university senatorium hospital and physical rehabilitation center in the hotsprings and forest area.

• When tourists arriving from other provinces at Esenboğa Airport is considered, investments should be made in this region due to its clean air and natural assets.

• Area should be given to the private sector and a high capacity complex should be formed.

• Procedures limiting the project can be overcome. Government should invest or private sector should be involved.

• Mineral content of each geothermal resource is different. Minerals of the project subject resource should be researched and ailments which can be treated should be identified.

2. Sectoral policies

• Civil population, State and Private Sector collaboration should be included in these efforts.

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• In the region there aren't people with adequate financial resources to invest in this project.

• Cooperatives can be established for construction and operations.

3. Model suggestion?

• We consider private sector and public collaboration under the leadership of University appropriate.

• Initially it should be for day tourism. Priorities should be given to regional publicity and marketing.

Notes of the Municipal Mayor of Çubuk:

“Three thermal areas in 18300 hectares at Özlüce were obtained. Use of this area for thermal and health tourism is desired. We are of the opinion that the resource referred is not suitable for greenhouse operations.

Our advantage is its proximity to the Esenboğa Airport. Direct international flights increased in recent years. YBU's establishment in this area is a great advantage. Physical therapy expertise of the Dean of Medical Faculty is added advantage.

Municipal Administration, University and MTA can form cooperation for drilling in different areas and joint health investments. Discussions should be held with the public and private sector.

University should obtain a near-by area of the region through a protocol with the municipality and commence activities immediately. We want university to invest in the drilling. All rights for the said area can belong to YBU.

Municipality is discussing the subject with private investors. But the University who will invest on behalf of the public sector should take the initiative for the area in its vicinity. Municipality donates this area to the University but the investments on it should belong to the YBU.”

Residents of the Özlüce Village:

At every opportunity they have emphasized that the hotspring originating in their village should be utilized primarily in their village. They indicated that this was the sole reason for their participation in the meeting.

They stated that they have no ideas with respect to Ankara’s place in health tourism or what should be done for its development, but they commented on their village's touristic potential.

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In order to discuss contribution to health tourism, it is necessary to establish resource's cure characteristics. Water's physical and chemical characteristics should be established as result of feasibility studies.

The pine and oak forests around the village, clean plateau air, dam, hunting, decorative plant production can be brought to the foreground, combined with hostsprings facility and it can be made a touristic attraction for national tourism in particular. For foreign tourism the primary impediment is foreign language. But this could be easily solved as economic potential grows.

If it is going to be used for tourism, they can form hostels through their own means.

Emphasized that they have confidence in the greenhouse activities of the Governorate, and through the hotspring, greenhouse heating problem can be solved, and decorative plants business which they know best can be further developed.

They have stated that the hotspring was discovered not by a special exploration but rather as a result of drilling intended for transporting water to the village from the near-by dam. Some of the land in this area was expropriated for dam construction and these lands can be used for the benefit of the village through use-right grants.

Indicated that they can gather 1 to 5 Million TL through methods such as cooperatives, but they need advice especially from the University as to how it could be invested. They have called for the reversal of economic migration from the village.

They indicated that the Çubuk Municipal administration should assist them in investments. The representative of the Municipality stated that the administration had other pressing commitments but they could obtain a symbolic seat and give every assistance during infrastructure building efforts.

Villagers emphasized a general opinion for most beneficial model consisting of university(technical support), people(capital), Municipality(infrastructure) and indicated that they do not prefer foreign investment. It was assessed that capital management should be done by a professional team(such as university consultancy service) paid by profits incurred. At this stage, their greatest disadvantage is lack of information and training, and this conclusion is attainable by the residents of Özlüce village who participated in the workshop.

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8 THERMAL COMPLEX PRELIMINARY FEASIBILITY STUDY

When a country's development level is being discussed, one of the criteria frequently used is the sum of investments realized in that country. The most basic condition for production of goods and services is the establishment and operation of production facilities. Transformation of funds and resources into investments is the fundamental caharacteristic of sustainable development. While the needs of the country and society, in particular those of individuals are limitless, the resources which will meet these are generally limited. For this reason with limited resources at hand satisfaction of endless needs is not always possible. Optimal use of resources and their redirection to most beneficial investment alternative is of extreme importance. At that point, a study is needed for each investment alternative in terms of its resource requirement and value added return it will provide. In our country these efforts are referred to as feasibility studies.

Investment refers to the transformation of monetary assets into phsyical assets for the purpose of establishing an operation. In other words, investment is an economic value which later returns monetary assets. Investments negatively affect the profits and increase unit costs of the operation for the period in which they were made, but upon completion and when revenue flows, they bring a rise in the profitability. The required condition for success in investments is basing of decisions on a rational analysis suited to the objective. Systematic and scientific studies which predict profitability and benefits of an operation prior to the final investment decision through economic, technical, financial, legal and cost analysis are referred to as feasibility reports. For this reason a feasibility report is also called 'establishability' or 'doability' research. A feasibility report is the totality of studies which provide multi-aspected benefits to the intended operation.

Hotsprings types which can be evaluated within the framework of Alternative Tourism may be classified as Sulphured Hydrogen, Saline, Sodium Chloride, Alkaline, Radioactive, Light acid, and Sulphured hotsprings. Cure indicators of these hotsprings are known to be neuralgia neuritis, acute and chronic arthropathies, dermatologic-acne, eczema, itching, allergic reactions, psoriasis,

55  

respiratory system ailments, goute, gynecological problems, post-trauma and post-operation ailments, and chronic exhaustion.

Counter indicators are advanced arteriosclerosis, newly formed brain ailments, heart arterial insufficiency, serious diabetes cases, malignous growth, active tuberculosis, inflammatory periods of rheumatismal diseases, acute periods of respiratory system imflammations, and heart conditions which cause swelling of lower limbs.

Table 5 provides information obtained on the subject thermal resource within the context of alternative tourism investment project.

Table 5: Thermal Liquid Chemical Characteristics, Özlüce ÇÖ-1 well, Özlüce-Dibecikdere Drilling (Source: Özlüce Geothermal Resource Operation Project, 2011, p. 28-38.)

Minerals in the liquid mg/lt.

Temperature °C 42

pH 7.3

Potassium (K+) 52.1

Sodium (Na+) 651

Calcium (Ca++) 37.7

Magnesium (Mg++) 23.2

Amonium (NH4+) 0.8

Boron (B) 8.2

Litium (Li+) 0.6

Bicarbonate (HCO3-) 1867

Carbonate (CO3--) <10

Sulphate (SO4--) 103

Chlorine (Cl-) 42.9

Fluorine (F-) 2

Nitrite (NO2-) 0.05

Nitrate (NO3-) 0.4

Phosphate (PO4) <0.1

Silica (SiO2) 38.7

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In the general classification of hotspring water done according to the guidelines of Association of International Hydrogeologists(AIH), analysis values of major elements have been calculated as miliequivalent percentages, and classification has been done on the basis of values exceeding 20%. According to this, the sample obtained from the ÇÖ-1 well is found to be sodium and bicarbonated thermal liquid class. ÇÖ-1 sample ion content is higher than that of other waters, and is thought to originate from deeper circulation, and from volcanic and gravel formations. ÇÖ-1 sample's cations are Na+K>Ca+Mg, anions are HCO3+CO3>SO4+Cl, and as such it belongs to a class rarely seen in nature and its carbonate alkaline is ranked among group of waters with high non-carbonate alkalinity. In the assessment made on Langelier calcium balance diagram, ÇÖ-1 sample has calcification characteristic. ÇÖ-1 sample exhibits non-suitability to crop irrigation (Özlüce Geothermal Resources Operation Project, 2011).

Chemical element and potential cure relationship of Özlüce ÇÖ-1 well is shown in Table 6.

Table 6: Chemical Element and Potential Treatment (Ledo,1996; Ernest 2011)

Element Potential Treatment

Calcium and Magnesium General nutrition

Sulphated water Hepatic anomalies and organic excretion accumulation problems

Bicarbonated water Gastrointestinal ailments, hepatic inadequacy and goute

Mineral water Goute, urinary track and kidney stone problems

Potential application areas of Özlüce ÇÖ-1 geothermal well is shown in Table 7.

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Table 7: Potential utility areas of subject geothermal resource

Potential Use Özlüce ÇÖ-1Water

Characteristic Explanation

Balneology and health tourism

Thermal For treatment purposes

Recreational tourism Thermal Spa

Nutritional supplement Thermal Spirulina

Geothermal/Medical training

Thermal Suitable for training

Considerations concerning health and thermal treatment affect the technical and technological design characteristics of the subject complex:

Hotspring cure treatment must be prescribed and monitored by a specialist or another expert physician.

Bath temperature must be 34-36°C, 36-38°C, 40°C according to preferences.

Bath sessions can be 3 to 6 days/week. Bath session period is average15-20 minutes. In some waters may be

extended to 30-40 minutes as per preference. One or two sessions may be applied per day. Total number of bath sessions on average per cure course is 15-20. Bath

cure continues minimum2 , maximum 6 weeks. Sufficient drinking water must be supplied. Swimming in the thermal pool should not be allowed, patients should be in

a standing or seated position with minimal movement. If in-water exercises are required, waters with a temperature of 34-35°C or

less should be used. Exercises in hotter water should be prohibited. Individuals must be properly dried after bath session and rest at least half to

one hour in a thermal comfort room with 24-25°C. Persons may be taken for massage or exercises after resting, and allowed

sporting activities. If required, physical therapy may be applied.

Thermal resource may also be used in the following areas:

Geothermal central heating of residences and facilities, and general use as hot water source.

Heating of greenhouses for various types of crops. Tropical plant and fish husbandry(including alligators as in Japan).

58  

Heating of chicken and feed animal farms. Heating of soil, streets, and airport runways. Use in swimming pool heating, and/or other touristic facilities.

In addtion to these there may be industrial applications:

Drying of food(fish, algea, moss, etc.) and sterilization, food preservation. Lumber operations, veneering industries. Paper production, weaving and dyeing. Drying of leather and processing, Fermentation and distilling in beer, etc. industries. In cooling facilities. Concrete drying. Use as drinking water after cooling.

Use in laundries for washing.

Other advanced industrial applications such as boric acid, ammonium bicarbonate, heavy water (deutorium oxide:D2O), ammonium sulphate, potassium chloride production and the CO2 amay be used in obtaining dry ice.

Depending on the chemical properties of geothermal resource, heating systems exhibit important variations. If suitable, it may be circulated directly in the afcility to be heated. However, if the water contains excessive soluables and chemically problematic(crustation, corrosion, etc.) it may be mixed with waters with lower chemical concentrations(e.g., city drinking water) with the aid of heat exchangers and used for heating. Heat exchanger systems may be at well-heads or in the wells depending on the specifics of the area. Efficiency, success or continuity of such applications depend on the proper use of technology.

Waters containing excessive chemicals preventing direct use and whose heat energy is transferred to clean city water via heat-exchangers must eventually be removed from the medium for protection of the environment though various processes. Thermal water with no heat may be reinjected to substrata in a way not to affect the thermal reservoir or underground waters.

Environmentally hazardous CO2 gas release is at minimal levels in thermal water resources. Use of geothermal resources as clean energy positively affect the environment.

In modern geothermal energy plants, the CO2, NOx, SOx emmissions are extremely low and especially in central heating systems the values are zero. In the new generation geothermal plants(Binary Cycle System), non-condensing gasses are removed from the steam and are reinjected underground with used

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thermal fluid, and nothing is released to the envirionment. These characteristics are important factors for the use of geothermal energy.

Thermal Complex Investment Model

In terms of health tourism, it would be appropriate to assess thermal tourism requirements in terms of profitability potential and sustainability. This model's objective entails maximization of profits through minimization of costs.

General suggestions for the model are given below:

1. Accomodation facilities must meet highest hygene expectations and must have an ambiance of relaxation and rest.

2. Positioning of complex facilities and the atmosphere they create must permit comfort.

3. All polluting activities must be eliminated. 4. Environment/Nature must be protected. 5. Food and alternatives must focus on healthy nutrition. 6. All facilities and equipment must be present for treatment and improvement

of visitors' ailments. 7. Health facilities should contain private small thermal jacuzzis for visitors'

rooms as well as hydrotherapy baths for general use(open air pools, steam baths, etc.).

Figure 15: Geothermal resource heat transferrability distances

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Thermal water transferred from source looses approximatley 1°C per 2.5kms. Figure 15 shows temperature losses after transfer.

8.1. Market Analysis

The model which is capable of servicing 840 persons per day with a 70% occupation rate is conceived to be capable of providing services for 300 thousand individuals annually. This amount may be affected by air passengers arriving at the Esenboğa Airport which is only minutes away from the facility by car. It is thought that in time it could become one of the leading health tourism centers.

It is foreseen that the service demand in the initial years(4-10 years) will increase progressively due to the tourism targets of Turkey's 2023 strategic plan including international superstructures such as the university and airport as regional characteristics.

Realization of the complexes within framework of the suggested model is seen as capable in responding to increased health tourism demand in addition to thermal tourism, and make Ankara an important center in terms of alternative tourism. Alternative tourism market size has a national and global growth trend.

When the 1.000.000 m3/year thermal flow creation of the subject investment project is considered, it can be seen that it has sufficient capacity to support alternative tourism. Additionally, future drilling and set-up of other wells in the area may increase the mentioned annual amount. Increased thermal resource flow amount may support alternative tourism and create new application areas.

8.2. Facility Location Analysis

In this section, location options and their relationships concerning the Alternative Tourism Complex are provided.

Complex Capacity Requirements

Some fundamental assumptions must be made in order to establish the facility's capacity requirements. These are:

30 lt/sec geothermal flow at 420C. Approximately 1M m3 lt/year thermal fluid.

Geothermal resource required for bath cure courses, 400lt/person/day

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Geothermal resource required for group therapy pool 6m3/person(recycles once every 24 hours)

Geothermal resource required for the thermal pool(1.4mx10mx20m = 280m3=280000 lt) will recycle once every six hours.

Private baths and treatment pool requires geothermal water resource(will remain max. 45 minutes, work 12 hours max., minimum 15 baths, activity period for purpose of treatment 12 hours, temperature will be lowered to 35°C -40°C)

Thermal characteristics which should be available at the facility:

Thermal jakuzzi Turkish bath Family baths Sauna Steam room Rest and recreation areas Gymnasium Outdoor and indoor pools

Accomodation at the complex:

10 suites 100 rooms each for 4 persons 200 rooms each for 2 persons Instantenous accomodations ~800 persons Instantenous visits ~1200 persons (accomodations included)

Personnel requirements:

Thermal therapy personnel(semi-professional) = 50 Thermal support personnel = 50 Technical personnel = 20 Health personnel = 40 Sports personnel = 20 Nutrition and Kitchen personnel= 50 Security personnel = 20 Other = ~100 Total = 350 personel

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It is also considered that spaces at the complex which should be in the forefront are Shopping Center, Cultural Center, Entertainment Center, Social Center, Cure Center.

Important factors for facility location selection

Certain factors step to the foreground in the selection of a site for an alternative tourism complex. Most important are proximity to the thermal resource and market. Additionally, some existing and potential factors are seen to be important in terms of complex location selection. These factors are(not listed in any particular order):

Proximity to the airport(important not only for the potential population who would benefit from alternative tourism, but at the same time for the provision of required equipment and materials, cultural impact, etc.)

Proximity to thermal resource Increased transportation options Shopping/commercial center(a commercial and convention center in

support of alternative tourism is considered effective within project scope)

Proximity to the health system(opportunity to benefit from the health units of the University)

Increased touristic demand in recent years for the country and region Absence of pollutants such as traffic, noise, and clean air and

environment Local characteristics University(scientific and cultural center)

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Figure 16: Alternative investment areas

Locale alternatives

Two separate areas are leading candidates for the complex site. First area(A) is in the vicinity of Özlüce village, and second area(B) is within the campus of Yıldırım Beyazıt University being built.

Alternative (A) is capable of providing a major cost advantage due to its proximity to the thermal source. As the complex site moves further from the thermal source the transport requirement for thermal water increases, which in turn causes additional costs for preservation of thermal heat during transportation and other extraneous expenditures.

Also, when a loss of 1°C per 2.5kms from the 42°C source is considered in terms of fluid characteristics and costs, the transfer of thermal resource from area A to area B incurs disadvantages. For this reason selection of area A as complex site is seen more meaningful.

Whereas alternative B is advantageous due to its proximity to the university campus area or its position within, in addition to being near to the market, means of transportation, international scientific, cultural superstructures and other facilities. But it has disadvantages in terms of transfer of thermal resource and recycling costs of the used resource.

Total costs of either alternative is foreseen to be similar. Furthermore, on the basis of Çubuk Municipal Administration's efforts being carried out and

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presence of other facilities in the area, it is seen as possible that other related resource exploration activities are expected to yield results supporting a facility constructed in area B.

It is thought that in addition to site selection analysis for A and B areas, other alternative points between these two areas should be considered and analyzed.

Thermal resource fluid may be used until it drops to 5°C. It can be reheated to 90°C and reused. But the cost of reprocessing will be high. It may be necessary to use it only for the support of thermal tourism and exclude alternative use fields.

Three alternatives emerge in the light of above information:

A. Area A as site of complex(cost effect = 0.8) B. Area B as site of complex (cost effect = 1.0) C. Area C as site of complex after completion of drilling activities (cost

effect = 1.0)

In this Conclusion report, alternative (C) is also included in the evaluation. All three alternatives are assessed under a single cost heading in this investment analysis.

Alternative tourism complex model is foreseen to contain a 20000m2 living area, total 7500m2 indoor area, and 5000m2 thermal indoor area. Largest thermal indoor area in Turkey is known to have 10000m2. The complex subject to this study should be dealt with in a manner permitting future expansion.

8.3. Technical/Technological Analysis

It is important to identify utility areas of the subject geothermal resource. When considered from this perspective, some utility areas are seen as appropriate:

80°C Home and greenhouse heating

70°C Cooling(bottom limit), health facilities

60°C Mushroom growing, baneological baths

40°C Soil heating, urban heating(bottom limit), health facilities

30°C Swimming pools, fermentation, distilling, health facilities

20°C Fish farms

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Additionally, alternative use areas for thermal resource fluid:

Greenhouse Soil heating Mushroom growing Fermentation Distilling Residential heating Fish farms

are considered to be explorable.

Technical requirements for thermal fluid use

Extraction Catchments: Built by special techniques such as Turkish Triangle, structures consisting of thermal water collection catchments, well galleries, drill-well dome centring and other facilities formed by mixed techniques which preserve the physical(flowrate, temperature, cleanliness, etc.) and chemical properties(including prevention of gas release and blending with surface waters) of the fluid during its extraction through natural or mechanical means.

Reinjection: Large volumes of hot water is obtained from geothermal reservoirs in which water is the primary output. Produced hot water is used directly in part, remainder is heat exchanged at centralized geothermal heating systems, eventually the fluid loses its heat energy and becomes excess water. Later this excess water may be released to the nearby sea, lake or rivers, but not all geothermal locations have access to these options. Even if they were available it would not be the correct solution and some envirionmental problems will become unavoidable. Correct solution therefore is its reinjection to the original source area or to appropriate substrata formations.

When excess water is reinjected to the thermal reservoir, significant benefits could be had. Obviously the diminishing reservoir volume is fed by deep natural flows but these feeds might not meet the amount of water removed from it, thus the reservoir pressure and well levels may drop. This problem is observed particularly in geothetmal systems where water is the primary factor. Solution is the reinjection of excess water to the source. Hence, the reservoir pressure is substantially preserved.

Reinjection process has 3 main objectives:

1. Removal of excess water from the surface. 2. Protection of reservoir pressure. 3. Obtaining more heat energy from the reservoir through recycling.

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Resource Protection Area: Whichever facility site alternative is preferred, it is essential to implement the necessary measures for the protection of the resource. In order to maintain thermal fluid contiunity and expansion of utility application areas, observance of the definitions below become mandatory.

Absolute Protection Area: This is the 300m wide horizontal land area from the edge of highest water level shore-line of artificial or natural lakes providing drinking or utility waters.

Short Distance Protection Area: From the outer boundary of Absolute Protection Area, 700m wide horizontal land area.

Mid-distance Protection Area: From the outer boundary of Short Distance Protection Area, 1km wide horizontal land area.

Long Distance Protection Are: From the outer boundary of Mid-distance Protection Area, the entire land area covering all of geographical and geologic catchment basin.

8.4. Financial Analysis

Including the marketing, project management and unexpected expenditures, 6.38% of the total general overhead expenses has been taken. The cost of general construction has been calculated with the data obtained from market survey. Total investment amounts are identified to include items such as Complex investment, Human Resource investment, Production investment, Recycling investment, Medical investments(Lab, etc.).

Revenue-Expenditure Analysis

In revenue analysis, values assumed to be average are used. Service prices in Turkey are visibly distinguishable from the global service prices. While global averages are seen to be 150TL/day for cure treatments, in Turkey this daily average ranges between 50-350TL. In this Conclusion report, 150TL is taken as the basis. Assuming an occupation rate of 70%:

Accomodation for 560 persons (150TL) Daily visitors 280 persons (50 TL) Total daily revenue = 98000 TL Total annual revenue = 35,770.000.00 TL

When the revenue-expenditure analysis is observed for the duration of operations, site alternatives A,B and C do not exhibit significant variations in revenue and expense items. But, in terms of total investment required, the cost

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differential which may be incurred due to thermal resource transport overland changes the financial analysis of the investment project.

Tables 8 and 9 depict the general revenue and expenditure items which should be included to the scope of this study.

Table 8: Alternative A, Revenue-Expenditure Items

Revenue Item Explanation Amount Accomodation Average occupation rate of 70%, 560

persons@150TL 30,660,000

Extras from accomadated guests 20% of the accomodation revenues 6,132,000 Bath treatments, Group therapy, Thermal jacuzzis,Steam rooms

200 persons@50TL@365 days 3,650,000

Swimming pools 100 persons@20TL@365 days 730,000 Cure center 80 persons@50TL@365 days 1,460,000 Commercial center Daily revenue 20.000TL@365 days x 2.5% 182,500 Convention/Conference center 12 conferences annually@30.000TL each 360,000 Sports areas and social facilities revenue 50 persons@20TL@365 days 365,000 Total 43,539,500

Expense Items Explanation Amount Personnel 350 persons@1000TL@12 months 3,500,000 Kitchen 300,000TL @ 12 months 3,600,000 Electricity+Mechanical+General 100,000TL @ 12 months 3,600,000 Financing Expenses 200,000 Other 200,000 Total 11,100,000

Table 9: Alternatives B and C, Revenue-Expenditure Items

Revenue Item Explanation Amount Accomodation Average occupation rate of 70%, 560

persons@150TL 30,660,000

Extras from accomadated guests 20% of the accomodation revenues 6,132,000 Bath treatments, Group therapy, Thermal jacuzzis,Steam rooms

200 persons@50TL@365 days 3,650,000

Swimming pools 100 persons@20TL@365 days 730,000 Cure center 80 persons@50TL@365 days 1,460,000 Commercial center Daily revenue 20.000TL@365 days x 2.5% 182,500 Convention/Conference center 12 conferences annually@30.000TL each 360,000 Sports areas and social facilities revenue 50 persons@20TL@365 days 365,000 Total 43,539,500

Expense Items Explanation Amount Personnel 350 persons@1000TL@12 months 3,500,000 Kitchen 300,000TL @ 12 months 3,600,000 Electricity+Mechanical+General 100,000TL @ 12 months 3,600,000 Financing Expenses 200,000 Other 200,000 Total 11,100,000

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Investments

Investment project plan has been provided for total complex investments projected for 10 years to be completed in 4 years. Investment period has been determined in consideration of thermal resource exploration durations, development of regional characteristics, preparation of scientific and cultural infrsatructure. Whereas the projection period is used as the period for demonstration of project profitability. The normalization period of revenues after completion of investments is included in the projection period.

Table 10: Alternative A, Investment Amounts

Investment Year

Activities Estimated Construction

Cost

Estimated General

Expenditure

Estimated Investment

0 Drilling Activities+ Reports on Thermal Fluid

800,000 160,000 960,000

Feasibility Study 60,000 - 60,000 Cost of Land 160,000 160,000 320,000 Project fees and development plan 160,000 160,000 320,000 Fees as per Article 18 of Development

Law + Ground Studies 96,000 160,000 256,000

Construction site buildings, ground works

1,200,000 160,000 1,360,000

1 Partial road construction+ground works

1,200,000 160,000 1,360,000

Rough construction 3,200,000 160,000 3,360,000 Rough construction+hot water drilling 3,200,000 160,000 3,360,000 Rough construction+codl water drilling 3,200,000 160,000 3,360,000

2 Rough construction +landscaping +infrastructure+purification

4,800,000 160,000 4,960,000

Construction refinements+Electricity provision and substation infrastructure

8,000,000 160,000 8,160,000

3 Hotel refurbishment 3,200,000 160,000 3,360,000 Commercial center 800,000 160,000 960,000 Thermal treatment facilities and

laboratories 3,200,000 160,000 3,360,000

4 Other investments 2,000,000 160,000 2,160,000 Total 37,676,000

Table 10 shows the estimated investment amounts for Alternative (A). Thermal resource fluid overland transportation or reheating process costs are not included. For this reason a cost factor coefficient is used. While the base cost coefficient for Alternatives (B) and (C) is taken to be 1.0, for Alternative (A) the coefficient for investment costs and general expenditures is taken as 0.8, and for revenues as 0.6, respectively. Reason for this is the assumption of lower investment cost and higher revenue loss in case of Alternative (A) preference.

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Table 11 shows the estimated investment amounts for the (B) and (C) alternatives. These investment amounts include overland thermal water transportation and reheating costs.

In the assessment of all three investment alternatives, investment items such as the land, human resources, production technologies, recycling technologies have been evaluated in general terms and reflected in the costs.

Table 11: Investment Amounts for Alternatives (B) and (C)

Investment Year

Activities Estimated Construction

Cost

Estimated General

Expenditure

Estimated Investment

0 Drilling Activities+ Reports on Thermal Fluid

1,000,000 200,000 1,200,000

Feasibility Study 75,000 - 75,000 Cost of Land 200,000 200,000 400,000 Project fees and development plan 200,000 200,000 400,000 Fees as per Article 18 of Development

Law + Ground Studies 120,000 200,000 320,000

Construction site buildings, ground works

1,500,000 200,000 1,700,000

1 Partial road construction+ground works

1,500,000 200,000 1,700,000

Rough construction 4,000,000 200,000 4,200,000 Rough construction+hot water drilling 4,000,000 200,000 4,200,000 Rough construction+codl water drilling 4,000,000 200,000 4,200,000

2 Rough construction +landscaping +infrastructure+purification

6,000,000 200,000 6,200,000

Construction refinements+Electricity provision and substation infrastructure

10,000,000 200,000 10,200,000

3 Hotel refurbishment 4,000,000 200,000 4,200,000 Commercial center 1,000,000 200,000 1,200,000 Thermal treatment facilities and

laboratories 4,000,000 200,000 4,200,000

4 Other investments 2,500,000 200,000 2,700,000 Total 47,095,000

Financial feasibility and project assessment

Net Present Value(NPV) generally used in the assessment of investment projects is assessed for Alternatives (A), (B) and (C) in terms of Internal Rate of Return, Pay-Back Period and Investment Recovery Rate.

Net Present Value(NPV)

NCV is frequently used in project analyses. It is a method of dynamic assessment. In this method, the annual cash receipts of the investment is summed on the basis of a discounted rate and the current value is found. Current value of the investment expenditures is subtracted from the current value of investment incomes.

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A : Current value sum of cash receipts

Ai : Net cash flows from the investment

C : Initial investment

r : Discounted rate

i : Annum

According to this method, for acceptance of a project, NCV must be equal to or greater than zero. In selection of alternative projects, priority is given to the project with highest NCV(providing that it is equal to zero or higher).

Internal Rate of Return(IRR)

IRR is the discount rate which equates NCV of cash income of a project for the duration of its economic life to the NCV of investment expenditures. Expressed differently, it is the discounted rate which equates the NCV of a project to zero. The discounted rate which equates the NCV of investment expenditures to the NCV of cash returns of the investment indicates the IRR of the investment.

NNAi : Net cash flows

I0 : Initial investment amount

İVO : Internal rate of return

According to this method, IRR calculated for a project must be greater than the minimum discounted rate accepted by the investor. In selecting among alternative projects, the project with highest IRR is given priority.

In order to make a preference among alternatives, the estimated cash flows for the alternatives are given in Tables 12 and 13. When the cash flows are closely examined, 6 years following the first 4 years of investment can be thought as the projection period. In this regard, while the total investment for Alternative (A) is estimated as 37.676.000 TL, and the total estimated investment for Alternatives (B) and (C) is seen as 47.095.000 TL.

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Table 12: Estimated cash flow for Alternative (A)

Negative cash flow for all alternatives in the first 4 years can be explained with completion of investments independent of facility site selection. on the other hand figures of general expenditures and revenue will be less in the first year in comparison to the remaining five years. The reason for this is the assumption that the productivity of the facility in the first year of operation will be less than subsequent years.

Table 13: Estimated cash flow for Alternatives (B) and (C)

Tables 14 and 15 exhibit the financial indicators of the alternative investment options. When examined closely, it is seen that there are values indicating short recovey periods for total investments of each alternative. Alternative (A)'s IRR is 23%, NCV is 22.397.000 TL, and recovery period is 18 months, and capital recovery rate is 69%. Alternative (B) and (C) has an IRR of 35%, NCV is 64.190.000TL, pay-back period is 18 months and capital recovery rate is 92%.

Table 14: Financial analysis of Alternative (A)

Internal Rate of Return 23% Net Current Value 22,397 Pay-Back Period 1,45 years Capital Recovery Rate 69%

When the financial indicators in Table 10 and Table 11 is considered, it can be concluded that all alternatives have investment supporting characteristics. On the other hand, Alternative (B) and (C) offers a higher investment profitability opprotunity as compared to Alternative (A).

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Table 15: Financial analysis of Alternative (B) and (C)

Internal Rate of Return 35% Net Current Value 64,190 Pay-Back Period 1,45 years Capital Recovery Rate 92%

Table 16 below shows the cost coefficients used for Alternative (A).

Table 16: Cost coefficients used for Alternative (A)

Cost Effect

Investment 0.8

Expenditure 0.8

Revenue 0.6

8.5. Evaluation of the Feasibility Study

Based on various scenarios such as varying total investments, general expenditures and revenues and suitability for investment, sensitivity analyses have been made for the pre-feasibility study provided in this Final report which may consitute the basis for the final project feasibility.

Table 17: Investment cost, expenditures and revenues according to optimistic, pessimistic and mid-range perspectives (x1000 TL),

Low

(D)

Medium

(O)

High

(H)

Investment amount 25000 50000 75000

General expenditures 25000 35000 45000

Revenues 10000 20000 30000

27 different scenarios have been developed against the risk of non-realization of values foreseen in this study and in support of decision taking (Table 18). Table 19 shows the rate at which financial indicators of all scenarios support the investment.

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Table 18: Cash flow of scenarios

Financial indicators concerning the scenarios are graphically depicted in Figure 17. Red lines in the graphics depict the pre-feasibility study results external to the scenarios.

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Figure 17: Graphics concerning the financial indicators of scenarios.

In order to assess the scenarios, it is important to establish all the cash flows and other financial indicators. Evaluation made in this respect and in the light of assumptions made upto now, the result indicating that 13 of the 27 alternative scenarios support profitability of the project directly, and 3 indirectly suggest

that the investment project is feasible with a ratio of (16/27 =59.26%)

(Table 19).

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Table 19: Evaluation concerning scenarios

As a result, all investment alternatives are foreseen as feasible(with the exception of scenarios). Alternative (B) and (C) is seen as more profitable than Alternative (A).

Preference between alternatives (B) and (C) is going to depend on the mission and vision of the decision takers of investors.

Subjects such as costs of drilling and level of professionalism, allocation and use of relevant rights, share provided to MTA should be kept on the agenda when a decision is being made with respect to the selection of operational model. In addition to this, after obtaining of the rights, institution/enterprise/partnership which will make the investment should be able to conduct its own technical works.

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9 CONCLUSION AND EVALUATION

Alternative Tourism Initiative: The Project of Thermal Complex Investment Analysis and Feasibility Report has been done within the framework T.R Ankara Development Agency's Direct Activity Support 2012 Program, and under the auspices and ownership of the Çubuk Governorate where the Çubuk Municipal Administration is a contributor and the Yıldırım Beyazıt University is a subcontractor.

General objective of this project is the "Identification of alternative tourism vision, strategy and policies in cooperation with university-local administration-civil society organization collaboration, and through determination of thermal tourism potential, rendering of Ankara province and in particular, the district of Çubuk(near Esenboga airport), a center of attraction for national and foreign tourists".

Among other purposes of the project are identified as the definition of strategies and objective investment projects which would transform Ankara's provincial tourism potential into practice, (1) Definition of a road map for the most optimal planning and execution of the thermal facility to be established within the campus of the University, (2) In order to develop the thermal tourism potential and infrastructure, formation of university-local administration-civil society organization collaboration, (3) Increasing of employment opportunities in the region through alternative tourism investments, (4) Offering of thermal services in a hotspring complex including a hospital, cure center, touristic facility infrastructures within the context of University.

Project's short-term expected results are seen as establishment of investment and operational model of the Thermal Complex planned for Esenboga through identification of health tourism vision and regional strategic objectives for Ankara; within the framework of permits obtained from the General Directorate of Mineral Research and Exploration for the Thermal Complex(thermal water well analysis, use rights, etc.) area, submitting of required applications to the Ministries of Tourism and Health; initiation of awareness creation on Health Tourism within the Ankara Region, and bringing of sectoral stakeholders together; definition of the Faculty of Medicine of Yıldırım Beyazıt University, the new State institution in Ankara and which began its foundation activities in the area of intended complex, as an effective stakeholder within the context of Health Tourism; establishment of a Web portal for wide dissemination of project results and for introduction of thermal

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complex to national and international investors, and initiation of relevant discussions with the investors.

Project's mid-to long term expected results are in the mid-term, primarily physical establishment of the thermal facility and commencement of operations in the Esenboğa area; clear and strategic positioning of health tourism in Ankara as an alternative tourism sector within the regional economy will be an important result in the long-term. Employment creation and capacity expansion affects in related sectors are siginificant economic gains; important progress will be achieved in public, university and private sector cooperation within the health tourism sector, and this collaboration will yield concrete projects. Increases in the number of national and foreign health tourists in particular will have positive effects on the region. In the long-term, this Complex's(as an thermal water and cure therapy) raising of the bar to a higher point in Ankara region can be defined as another positive result.

Alternative Tourism Initiative: As a result of studies made within the framework of Thermal Complex Investment Analysis and Feasibility Report, an investment for a health and thermal treatment center in the region is seen as financially profitable in a 10 year period. In addition to its financial characteristics, it is evaluated that in time the regional cultural and economic contribution will be very important in terms of alternative tourism.

Recreational areas, facilities supporting health tourism, thermal treatment opportunities, preservation of regional characteristics, and suitability to nature sports and activities are important in terms of making it a center near Ankara, airport transportation, and the university scientific contribution, cultural advantage and internationality.

In contrast, the regional potential is dependent on the drilling for thermal resources. These efforts will not be relevant and valuable only to thermal and health tourism, but also to various potential applications mentioned in the report.

In addition to the potential which may arise in the region with the effect of Aydos Mountain on the nature, health and thermal tourism fields, it also presents an opportunity especially in suport of chest diseases and physical therapy medical areas. Regional climate is seen to be utilizable in this respect from the perspective of Ankara.

Implementation of required efforts for the expansion of utilization areas of geothermal resources in the region, presents various opportunities as in other countries for:

Central heating of buildings and towns, and utility as general use hot water,

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Greenhouses heating for the production of out-of-season decorative plants, fruit trees and vegetables,

Tropical plant and fish husbandry, Heating of chicken and feed animal farms, Soil, street, airport runway heating, Drying of foods, sterilization and use in food preservation, Use in lumbering and veneering industry, Use in paper, weaving, and painting, Drying of leather and processing, Fermentation and distilling in beer and similar industries, Use in cooling facilities, Drying of concrete blocks, Use as drinking water after cooling, Use in laundry facilities.

Other advanced industrial applications such as boric acid, ammonium bicarbonate, heavy water (deutorium oxide:D2O), ammonium sulphate, potassium chloride production and the CO2 may be used in obtaining dry ice.

In the light of information reported so far, regional scientific and cultural contributions which can be made by the Yıldırım Beyazıt University, and others by Esenboğa Airport with due respect for the preservation of natural assets are important. It is assessed that for sustainable regional development, instead of considering the subject only from the perspective of thermal tourism, it is necessary to deal with the subject of alternative tourism from a wider perspective.

Support of the existing regional greenhouse activities and expansion of decorative plant production gains more importance with pioneership in this field. Development of bilingualism abilities of local residents is also important in terms of bringing together various global characteristics with localized opportunities.

When considered from the perspective of operations, instead of targeting an alternative tourism center with traditional characteristics, preference of a model which includes regional features as well as natural resources is seen more advantageous. In this respect, financial partnering of regional population, even at a low level, will come to the foreplan. From the perspective of investors, it will not be inaccurate to state that the various types of partnerships in which Yıldırım Beyazıt University is involved will be economically profitable for the

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region, and manifest itself socially interms of the university and culturally for the local population.

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Ministry of Health, Hotsprings Regulation

Servet Yılmazer(b.t),Batı Anadolu’nu lası Jeotermal Potansiyelinin Belirlenmesi

Tshibalo, A.E. (2011). Health Spa Tourısm: A Potentıal Use Of Sagole Thermal Sprıng In Lımpopo Province, Kenya Geothermal Conference.

Regulation Concerning The Use Rights of Thermal Waters Located in Tourism Areas and Centers, and Their Operation Principles and Procedures.