First published in ITIJ 135, April 2012
With an increase of almost 10 per cent in international visitor numbers in 2011, Turkey continues to be one of the world’s fastest growing destinations. Is its healthcare and medical assistance infrastructure keeping pace? Robin Gauldie reports
Turkey is one of the outstanding tourism success stories of the last two decades. Until the late 1980s, it could hardly be considered as a mass-market destination, though its cultural attractions and unspoiled coastline attracted reasonable numbers of independent travellers. In the late 1980s, low prices gave Turkey a competitive advantage over its biggest tourism rival, Greece, and over other European Mediterranean destinations. Major European tour operators and hotel groups took an interest in developing the country’s Aegean and Mediterranean coasts, new airports opened up fresh areas to international charter arrivals, and by the early 1990s the tourism boom was well and truly on. With minor interruptions, growth has hardly slowed since then. Tourist numbers passed the 10 million mark in 2001 and by the end of 2011 had reached 31.46 million, an increase of 9.86 per cent over the previous year.
Successive governments have carried out a series of reforms that have modernised and diversified the nation’s economy and stabilised its currency
Tourism growth is only part of a broader success story. Successive governments have carried out a series of reforms that have modernised and diversified the nation’s economy and stabilised its currency. Tourism may contribute more than US$20 billion in foreign exchange earnings, but it represents only seven per cent of GDP, in sharp contrast to more tourism-reliant countries. Turkey has become a regional economic powerhouse, with Turkish companies involved in major infrastructure projects such as Tunisia’s new Enfidha international airport and Gaza’s new, US$35 million Teba Hospital. To an extent, this economic success has removed Turkey’s price advantage as a destination, with prices for many tourism-related commodities and services now on a par with comparable European Union (EU) nations. Recent surveys have even suggested that Turkey is now more expensive for holidaymakers than Spain.
Everything to offer
But Turkey’s tourism success has been built on far more than bargain pricing. Diversification, in terms not only of source markets, but also of tourism products and destinations within Turkey, has been key to its remarkable success. In its early boom years, Turkey was heavily dependent on the major European tourism source countries, especially the UK and Germany. These markets have continued to be significant, but Turkey has also become a popular destination for Russian and Ukrainian holidaymakers and to visitors from the Middle East. As a result, Turkey is much less vulnerable, in tourism terms, to currency fluctuations, economic problems in any single source market, or tour operator failures.
In the 1980s and early 1990s, most accommodation offered by European package tour operators in Turkey was in small, purpose-built hotels and apartment complexes, many of which were part-financed by large European tour companies in partnership with local tourism entrepreneurs, or in large, conventional three-star hotels. Since then a plethora of new properties have opened. The accommodation mix includes ultra-luxury palace hotels in resorts and in Istanbul, boutique townhouses, small hostels, purpose-built apartments and all-inclusive complexes.
While May to October continues to be peak season for the mainstream coast resorts, Istanbul has become a year-round destination. Many large resort and city hotels have also successfully developed the meetings, incentive travel, conference and exhibitions (MICE) market to fill rooms in winter and in the spring and autumn shoulder seasons. Turkey’s climate can be extreme, with temperatures rising as high as 40°C in midsummer and plunging well below zero in winter, with heavy snow on the high country of Anatolia and even in Istanbul.
Turkey offers a tremendous variety of landscapes, from the rocky coasts and mountainous hinterland of the Lycian coast to the miles-long golden strands of the Mediterranean coast, east of Antalya, as well as a vast hinterland of plateaus and impressive mountain ranges.
The human landscape is equally diverse, ranging from pretty harbour villages such as Kas and Kalkan to cities such as Marmaris, Bodrum and Kusadasi, where purpose-built resort areas surround historic centres.
Diversification, in terms not only of source markets but of tourism products and destinations within Turkey, has been the key to Turkey’s remarkable success
Istanbul, Turkey’s largest city, is now well established as a citybreak destination, its ancient Byzantine and Ottoman heritage enhanced by great food, outstanding shopping, superb museums and some of the finest hotels in Europe. Luxury thalassotherapy and spa holidays are also popular (Turkey is, after all, the birthplace of the hammam or steam bath) and most luxury properties in resort areas and in Istanbul feature health and beauty facilities operated by world-class spa brands. Throughout Turkey, ancient history is a powerful draw for cultural tourism, with the relics of some of the world’s most ancient civilisations and great religions dominating city centres or standing on deserted mountainsides.
Cruise tourism is another growth area, and the port of Kusadasi has become a major port of call for cruise passengers visiting ancient Ephesus and its Temple of Diana, one of the seven wonders of the ancient world. Religious tourism also draws pilgrim groups, mainly from the US, to historic Christian sites including Ephesus, Demre, and Istanbul.
Activity holidays are also significant, with a plethora of more or less risky activities on offer, from diving, sailing, windsurfing, jet-skiing and other powered watersports to winter sports, white-water rafting, hang gliding, micro-light flying and hot air ballooning. The challenging 509-km Lycian Way is popular with determined hikers, demanding a high level of fitness, while the ascent of 5,137m Mt Ararat in Turkey’s far east attracts even more adventurous travellers.
Clearly, all of these generate demand for claims and assistance ranging from simple minor injuries to life-threatening accidents and deaths. In 2009 a British tourist was killed and nine others were injured when their hot air balloon, operated by Cappadocia Balloons, plummeted from a height of 50 metres after a mid-air collision with another balloon. Goreme in Cappadocia, famous for its spectacular rock pinnacles with their early Christian cave-churches, has become a popular centre for hot-air ballooning, with up to 45 flights every day in season.
No surprise, then, that a certain cynicism greeted an announcement that Turkish company VIP Tourism has begun taking bookings for balloon flights into the stratosphere, starting in 2014. The flights, using a state of the art craft trademarked ‘Bloon’ by its Spanish developer, will take four hours, reach an altitude of 36,000 metres, and will cost €110,000 euros. Chief executive Ceylan Pirinccioglu said the company had located sites in Konya and Eskisehir provinces as potential ground bases.
The rapids of the Dalaman River, close to some of the coast’s most popular resorts, have also been the scene of fatal accidents involving tourists. Richard Manning, a 66-year-old Briton, died after his boat flipped over in October 2009. Nine-year-old Cerys Potter died in July 2010 when the inflatable raft she was on capsized. Raft capsizes are said to be common on the nine-mile stretch of rapids (rated as ‘grade 4’ in difficulty on the commonly used whitewater sports industry scale of 1-6), and there have been suggestions that safety standards are lax.
With a land area of 780,580 km2 (more than twice the size of Germany and half as big again as France), Turkey has a population of almost 79 million, around 70 per cent of whom are city dwellers. Many of the country’s largest urban areas (notably Istanbul, with a population of more than 10 million) have grown dramatically in the last 20 years, mainly as a result of an accelerating ‘drift to the cities’ by rural work-seekers.
Travel to the far east and south east of the country, where Turkey borders Syria, Iraq and Iran and where Kurdish separatists have been active for decades, can be interrupted by clashes between Kurdish armed groups and the security forces, and military checkpoints are common on roads in this part of the country.
the vast majority of visitors are concentrated in a relatively small area, along the coast from Izmir in the north to the Antalya area in the south, and in Istanbul
The UK Foreign Office warns of ‘a high threat from terrorism’ and advises against all but essential travel to the provinces Hakkari, Sirnak and Siirt, on the Iraqi border, and Tunceli province, in eastern Anatolia. Turkey’s border with Syria is heavily militarised, and should violence by government forces against the Syrian opposition escalate any further, or even develop into full-blown civil war, there are obvious security implications for Turkey.
Non-political gun crime is also an issue. Some 40 million people are estimated to have access to firearms in their homes. Nationwide, Turks own up to eight million firearms, only 2.5 million of which are registered. Around 3,000 people a year die in shooting incidents each year. Around 700 die accidentally, as a result of the national habit of firing celebratory volleys at events such as weddings and after football matches.
Nor is Turkey immune from natural disasters. Up to 600 people died in earthquakes in the Van area of eastern Turkey in October and November 2011. The earthquake that struck the densely populated northwest in 1999 took a much heavier toll, leaving some 18,000 dead.
The country’s geography presents some challenges for medical assistance companies. The distance between Turkey’s European border with Greece and its eastern border is around 1,700 km. Terrain is extremely varied, with rugged mountain ranges within sight of popular coastal resorts, swathes of semi-desert in the remote south-east, and peaks high enough to remain snow-capped all year round in the far south east.
However, Turkey’s transport and communications infrastructure is generally good. In addition, the vast majority of visitors are concentrated in a relatively small area, along the coast from Izmir in the north to the Antalya area in the south, and in Istanbul.
Most of the road network, at least in cities and in the most popular tourism areas, is generally as good as those anywhere in Europe, with a network of four-lane highways connecting major cities. However, reckless driving and poorly maintained commercial and agricultural vehicles contribute to more than one million road accidents and some 4,000 fatalities yearly.
The development of international airports at Izmir and Dalaman on the Aegean coast, and Antalya on the Mediterranean, has turned these areas into the main hubs for sun and sand tourism, and massive expansion of air capacity into Istanbul by low-cost airlines has made the city much more accessible and affordable for short-break visitors from all over Europe and elsewhere. Ankara, Turkey’s capital, is less popular with leisure visitors but is a major business and meetings destination and is well served by Turkey’s national airline Turk Havayollari (Turkish Airlines) and other major international carriers.
In all, Turkey has 16 international airports, including two in Istanbul. These are complemented by more than 30 domestic airports that connect regional capitals with Ankara and Istanbul. Independent airlines including Atlasjet, Pegasus, Onur Air and Sun Express complement and compete with Turkish Airlines’ internal flights and also operate some flights to Europe and the Middle East.
Aeromedical operations are facilitated by the wide availability of civilian airports. In addition, Turkish military search and rescue aircraft can deploy from numerous military airfields and helipads. The Turkish Air Force operates around 20 Cougar search and rescue helicopters, built in Turkey in a joint venture between Eurocopter and Tusas Aerospace Industries, and its pilots are experienced in operations in extreme terrain and remote areas.
State-operated civilian air ambulance services are operated by Sky Line Transportation, a division of the Kocoglu Aviation group, under contract to the Ministry of Health, using a fleet of 19 helicopters and two fixed-wing aircraft, operating from bases in 15 cities around Turkey. In November, the Ministry of Health added two Hawker 900XP aircraft from Spectrum Aeromed to its fleet of three Hawker900XPs and one King Air 350 air ambulances.
At sea, search and rescue (SAR) missions are carried out by the Turkish Coast Guard, which is due to take delivery this year of four new purpose-built SAR vessels from Turkish shipbuilder RMK Marine. With cruise ships, tourist gulet schooners, private yachts and international ferries plying the coast, as well as clandestine vessels carrying illegal migrants seeking to enter the EU by crossing from Turkey to Greece, maritime SAR missions can also be complicated by jurisdictional issues between the two countries, because in many places only a few kilometres separate mainland Turkey from the islands of eastern Greece.
Most private clinics and doctors require immediate payment by cash or credit card
Private air ambulance operators include Redstar. Launched in 2002, the company is headquartered at Istanbul’s Sabiha Gokcen International Airport, with regional bases in Izmir and Trabzon, on the Black Sea coast. The company operates a BAE Jetstream 32EP and a Eurocopter BO105 helicopter, both equipped for intensive care, received ISO 9001 certification in 2003 and is Joint Aviation Authority compliant.
Providing a bridge between hospitals in Turkey and abroad, aeromedical rescue services, and insurance companies, Stars Crescent Assistance (SCA)
offers multi-lingual medical staff and claims to be capable of providing insurers with almost continuous updates on the patient’s clinical condition.
SCA recognises that there can be communication problems between international insurance medical staff and attending physicians in Turkey, and specialises in easing such communication issues.
Cash for care
In Turkey’s major cities and resort areas, many doctors and hospital staff speak some English and German, as do pharmacists, who can also provide first aid and basic health advice and diagnosis. Pharmacies also sell a range of remedies, such as antibiotics, which are available only on prescription in the EU and some other European countries (and almost all have prominent window displays advertising over-the-counter Viagra).
Turkey is not a member of the EU, and European Health Insurance Cards (EHIC) do not entitle visitors to free healthcare. Most private clinics and doctors require immediate payment by cash or credit card (Visa being the most widely expected); however, most large private hospitals have agreements in place with major travel and health insurers.
The Turkish state still dominates the healthcare sector, with a constitutional mandate to provide health, hospital and pharmaceutical services through a network of public hospitals and clinics that receive most of their financing from the government, with around 13 per cent derived from fees paid by insurers or individual patients. There are plans to rationalise the complicated state healthcare system, which has historically been dominated by three separate social insurance funds.
According to Dr Hans Biekmann, who took over as chief executive of Turkish assistance company MARM Assistance in December 2011, there are still significant differences in standards between public and private hospitals, attributable to underfunding, understaffing, and overcrowding.
Thanks to the country’s remarkable economic performance over the last two decades, more Turks can now choose private healthcare and private medical insurance. As a result, Turkey has a plethora of large and sophisticated private hospitals.
there are significant issues around over-treatment, over-charging and unnecessary bureaucracy
“Every single hospital in Turkey, be it public or private, possesses an emergency unit and trauma centre,” says Biekmann. “Finding an emergency unit, even in the most remote areas, would not be difficult.” Nevertheless, he says, the quality of emergency units at university hospitals and Joint Commission International (JCI) accredited private hospitals is significantly higher than those of small private and state hospitals. The private healthcare sector in the country continues to expand, with more than 40 JCI-accredited hospitals boasting the latest technology and foreign-trained doctors and medical staff.
“We can confidently say that standards now meet and even exceed the quality of those found in Western Europe.” But, he says, there are significant issues around over-treatment, over-charging and unnecessary bureaucracy, so cost containment experts are almost essential partners for international insurers. By closely monitoring the treatment provided by hospitals, MARM says it can save insurance companies an average of 20 per cent on hospital costs. “We have even had cases where the insurance company saved 70 per cent of their patient’s bill,” Biekmann claims.
Turkish private hospital groups have also attracted international investors, and some Turkish private healthcare providers are exporting their expertise to Eastern Europe, the Middle East and Asia. According to Pinar Lembet, vice general manager of finance at the major private hospital chain Acibadem, the private healthcare sector in Turkey is divided into ‘Group A’ hospitals that cater mainly for patients who have opted for full private medical insurance: “Essentially, the 1.5 per cent of the population with healthcare insurance, plus cash payers.” Group B hospitals cater for the much larger middle class, who use public insurance to partly pay for the service, and then pay an extra 30 per cent for private care.
Acibadem, recently acquired by the healthcare division of Malaysian investor Khazanah Nasional, is now the second-largest hospital group in the world, with 11 general hospitals as well as a network of outpatient clinics and diagnostic laboratories. The Medical Park hospital chain, with 17 facilities across Turkey, was acquired by the US Carlyle Group in 2009, and now plans to export its expertise to nearby destinations, including Romania. Universal Hospitals Group, with 18 hospitals in 12 of Turkey’s large cities, has attracted a US$140-million investment from investors led by ADM Capital, to fund further expansion of its healthcare empire. Kent Hospital Group, based in Izmir, has recently been acquired by investment group Mid Europa.
Driven by strong demand from Turks themselves, strong government involvement and a surprisingly healthy national economy as well as seemingly unstoppable growth in tourism, Turkey’s medical and assistance infrastructure appears well capable of meeting the needs of visitors and their insurers, and indeed seems set to export its expertise across neighbouring regions.