Sustainable development and management of medical tourism companies in Poland

In an interview for El Paris, former US president Barack Obama concluded that “disregard for science, disregard for facts will only worsen the pandemic. Encouraging or even only tolerating racist behaviors encourages those who have such tendencies. Supporting various dictators diminishes involvement of the liberal world for democracy” (Obama 2020b, p. 4) (Obama 2020a), is a short description of changes for the nearest future.

In this context, it is worth looking at the scholarship's attempt to characterize the above-mentioned behaviors, in the contemporary era moving toward Economy 4.0. Koźmiński concludes: “Already today I can see eight observable most important conflicts which will shape the next century:

Rationality versus emotions in collective human activity,

The concept of sustainable development is a certain idea that creates a chance to meet the above challenges.

In the last decade, we have observed a growing interest in the concept of corporate social responsibility (CSR), on the part of both business and society (Hartmann, 2011).

Lasting and sustainable development is a process that is characterized by striving to achieve lasting economic and social development through ensuring access to renewable and nonrenewable resources, improvement of the quality of life in a clean and natural environment, economic growth taking place through more effective use of raw materials and other nature's resources, rationalization of the use of energy and labor, and also development of pro-ecological technologies as well as protection of the environmental and cultural heritage (Hull, 2005). Now, it is a major challenge for human activity associated with i.a., tourism and also for a contemporary metropolis in its efforts for sustainable development (Koźmiński, 2020).

Sustainable development of a metropolis assumes constant improvement of life conditions of its residents and at the same time protecting the natural environment. The care for an appropriate health status of residents plays a specific role in the achievement of the above goal. Moreover, this mainly depends on the development of medicine and residents’ life activity, which, in turn, is sometimes associated with the development of recreation as well as tourism. As noted by Rab-Przybyłowicz (2016), it is crucial, since market success increasingly depends on the capability of supplying products that stimulate senses, evoke feelings, and engage emotions.

In the 1960s and 1970s, various circles on the international arena began to note the negative impact of economic development on the natural environment. This is when the concept of sustainable development was born.

Sustainable development is perceived at the international level as a leading trend in social, economic, and ecological development—in both a macro- and microeconomic angle.

In 1987, a report of the UN World Commission on Environment and Development (WCED) titled “Our Common Future” was published, which greatly influenced the advancement of the concept of sustainable development. According to the published document, the aim of sustainable development is to meet the needs of present and future generations while fully respecting the natural environment (WCED, 1987). The report contributed to the preparation of the 1992 Rio de Janeiro Earth Summit, during which 178 countries signed a declaration on the implementation of sustainable development as a principle of global environmental and development policy. The document included a postulate, according to which all people, all societies, and all generations are entitled to a healthy and productive life and development in harmony with nature (United Nations, 1992). Thus, sustainable development means a process directed at meeting development-related goals of the present generation in such a way that the same needs of next generations can also be met (Borys, 2011). Definition-wise, sustainable development is understood as a normative concept, which takes into account ethical norms and values applicable in a given society and that are necessary to its development.

A classic definition was included in the WCED report. It is present in literature on sustainable development and provides a number of new interpretations, depending on the degree of aggregation and a thematic area. Despite this, there is a noticeable absence of a precise and consistent meaning of this term, which may be evidenced by close to 300 definitions of sustainable development (Johnston, Everard, Santillo, Robert, 2007).

The general consensus concerns directing sustainable development toward a long-term perspective and taking into account the ecological, economic, and social aspects. This approach is represented by various authors such as jak Norgaard (1989), Bugge, Watters (2003), Sneddon, Howarth, Norgaard (2006), Mierzejewska (2009), and Petrişor, Petrişor (2013).

Organizations such as the UN, the European Union and the Organization for Economic Co-operation and Development (OECD) considered the need to change the current model of economic development into a more sustainable one as one of the priority areas. Such a need is also seen by the World Bank, UNCTAD, UNIDO, WTO, and FAO—it is a need for a global transformation in the direction of green economy, which cannot be imposed top-down, but must be developed by business operators. They must be operators who are able to respond effectively to policy stimuli by implementing innovation in management and technologies. Ecological products and modern technologies are ultimately introduced to the market by the so-called eco-entrepreneurs who implement their ideas by transforming prototypes into profitable eco-friendly products. Medical tourism business operators, in turn, try to provide their services with particular respect for the natural environment.

Enhanced efforts on the international arena are reflected in the new Sustainable Development Goals (SDGs), which were set out at the UN level as part of the new 2015 development agenda with the 2030 perspective (United Nations, 2015). The new agenda, based on the document Transforming Our World: The 2030 Agenda for Global Action (UN, 2015) specifies 17 main goals and 169 related targets. Goals 8, 9, and 12, which directly refer to sustainable development at the company level, are particularly noteworthy (UN, 2015). They emphasize i.a., promotion of development policy that supports productive activities, services, entrepreneurship, creativity, and innovation. It supports encouragement of development of micro-, small-and medium-sized enterprises, and also introduction of sustainable development of industry by enhancing effective use of resources and application of clean and eco-friendly technologies and production processes. These, in turn, are especially important in tourism and in the medical industry.

Summing up, SDGs, in a strategic approach, provide new possibilities of development for companies. They give an opportunity to build a lasting and long-term competition advantage and its essential sources include improvement of reputation, and possibility to create and develop innovative products and services that will correspond to the needs of ever more conscious and responsible consumers.

Next to typical forms of tourism and its types, new ones arise, which gain a significant market position with time. Currently medicine and tourism are interconnected. Medicine contributes to the emergence of new types of tourism.

It is extremely difficult to define unequivocally the concept of medical tourism, since in practice it is often identified with traveling to a remote corner of the world to have a plastic surgery procedure done or undergo broadly defined surgical procedures. This difficulty results from the fact that today the customers/tourists, pursuant to the transboundary directive, have the right to undergo various procedures in neighboring countries, but in Poland, for example, they can also travel to a different voivodship to avoid queues.

The author defines medical tourism as travels (movement) of people (independently or accompanied) to a different region or country to undergo a planned medical procedure to improve their appearance or quality of life, or to save their health, where these travels are done because of the price of the service or unavailability of the service in their country of origin for technological reasons or due to legislative restrictions, or because the waiting time for a medical procedure is too long (Wiśniewska, 2020).

In the time of the universal cult of good health and beautiful body an increasing demand for medical services is observed, also for tourists who while visiting a given country undergo procedures improving their health or appearance. Medical tourism involves travel, staying outside a permanent place of residence, during which a tourist undergoes esthetic medicine procedures, plastic surgery, or procedures improving appearance. Improvement of the standard of life of various social groups, increased importance of the cult of beautiful body, and the need for discretion in such procedures encourages the development of medical tourism. Regulations that allow refunding procedures performed in voivodships other than the patients’ regular place of residence meet these expectations, and so does refunding of certain procedures under specific terms in neighboring countries as well as throughout the European Union. The development of medical tourism is determined by the availability of procedures in legal terms (e.g., degree of facial change) and the price of services, their quality, and available dates of their performance.

Development of the services sector is a very noticeable trend in contemporary economies. It affects consumption, production, and also exchange. The sphere of production ensures delivery of effective work measures, improvement of qualifications, and regeneration of employed persons. In the exchange sphere, the sale and purchase of services occurs, whereas in the consumption sphere, the function of a service involves boosting the life sphere (Dębowska, 2011:43). When demand for specific services is satisfied, demand for completely new ones, unknown or not easily available, appears (Węgrzyn, 2017). As provided by Eurostat, in Poland in 2017 the services sector employed 59% of the total working population, industry—31% of the employed, whereas approximately 10% of people were employed in agriculture.

In Poland, the number of people employed in the services sector rises every year and it is a trend also visible throughout the European Union. Both in Poland and in the European Union approximately 70% of the total working population is employed in the services sector. The development of this sector is a determinant of advancement of economy's characteristics in developed countries. Innovative solutions and modern technologies are increasingly used for the development of the services sector. The tourism market is formed of entities involved in tourism and they include companies providing transport, accommodation, catering, insurance services, travel offices, and others. The market of tourist businesses is dominated, both in Poland and in the European Union, by micro-, small- and medium-sized enterprises (Rzepka, 2018). Due to the nature of the offered goods and services related to tourist values and attractions, the tourist market is specific and requires a qualitative look, created by a self-government, public administration, in a local, regional as well as national scale (Bednarczyk, 2010:78).

Social changes, globalization of economy, and transformations that take place in terms of leisure time make it necessary to take these factors into account in a classification approach to times and forms of tourism (Panasiuk, 2017:68).

The author carried out research in 2018–2019 on the management of companies in medical tourism. In all, 214

The number of investigated companies results from their availability for the study. The author is aware that is was a certain fraction of companies of this type (medical tourism) operating in the listed voivodships.

The aim of the study was to analyze the macroeconomic sector of medical tourism and to demonstrate, through empirical research, the possibility of business use of the opportunities to expand medical tourism in Poland. Therefore, it is reasonable to point to the parallel nature of the increase in the interest in medical tourism to strengthen sustainable development. The paper is based on a certain selected part of empirical research carried out in the said years. Participation in the research was determined by the author's possibility to reach the companies and to conduct the research. The research results need to be viewed as an attempt to conceptualize the problem, the solution of which enforces further research.

The research shows that among the 214 surveyed entities, 31.4% were registered partnerships, 29.5%—limited liability companies, 25.7%—natural persons operating a business activity, 8.6%—civil law partnerships, 3.8%—joint-stock companies, and 1%—limited partnerships.

Among the 214 surveyed companies, 48% have been operating for 8 or more years, 40%—4–7 years and only 21%—1–3 years. When analyzing the above data, one may conclude that medical tourism companies have a few-percent dynamics of annual increase in their number. Of the investigated companies, 42.5% had a nationwide reach, 45.3%—regional, 8.5%—local, and 3.8%—international. As many as 93.1% companies operated in cities.

The respondents generally had worked for a few years in their current company. Fifty percent respondents—4–9 years, 31.1%—up to 3 years, 17% had worked there for 13–15 years, and 1.9% declared having worked in the company for a long time—6–20 years. It is characteristic that as many as 40.2% declared their total work experience as 16–20 years and 37.4%—11–15 years. Therefore, in may be concluded that employees of a medical tourism companies often have long work experience. Today the industry is developing dynamically, which was demonstrated by the frequency of changing jobs and an increase in the number of companies of this type.

Factors associated with the development of the companies and barriers affecting this development were an important area in the study.

Respondents declared the following as factors facilitating the development of the companies: funding from the European Union—67.9%, new regulations—48.1%, funding from the labor fund—23.6%, low-interest loans for company development—19.8%, others—9.4% (subsidies from the employment office for employing a new employee, favorable bank offers, including loans on preferential terms).

In the opinion of respondents, the factor that hindered company development the most was the change of the price structure (fuel, energy, raw materials)—76.4% responses. More than two out of three respondents (67%) pointed to a changeable market situation. Immediately after, came difficulties in accessing bank credit (41.5%) as well as shortage of employees and changing law (31.1% each). The factor that the fewest number of respondents pointed to was irrecoverable debts—10.4% responses (Wiśniewska, 2020).

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Apart from the abovementioned areas, the use of character features is important in medical tourism. As many as three-quarters of respondents pointed to empathy (77.4%), ability to provide information suggestively (75.5%), and integrity. Kindness and ability to establish contacts were pointed to slightly less frequently (69.8% and 65.1%, respectively). Whereas punctuality was seen as least important by respondents—38.7% responses.

The main premise to initiate interorganizational cooperation is the need to go beyond knowledge resources available in a given company. The role and benefits of interorganizational cooperation are constantly increasing. Thanks to the cooperation of companies, it is possible to create innovative products and services (Rzepka, 2018) since only a small percentage of companies are able to operate independently. Establishing and developing interorganizational cooperation gives an opportunity to achieve the most beneficial position competition-wise. By establishing interorganizational relations with partners, the company may make its market offer more attractive and improve it, and it may also expand its knowledge on new outlets (Klincewicz, 2016).

Results show that cooperation with organizations from the environment is rather modest. When analyzing the determinants of the establishment and development of companies in medical tourism, one may assume the reason behind the relatively frequent cooperation with consulting companies or travel agents. It seems that companies in medical tourism are largely in the stage of development on the current market. Certain optimism is inspired by the data concerning companies’ opinions on enhancing resources of knowledge, information, and the resulting cooperation with other organizations. Of respondents, 77.1% declare that such enhancement of resources occurs as a result of cooperation; 21.9% state that it is “difficult to say,” but only 1.9% speak negatively about the significance of cooperation in enhancing knowledge.

Results of investigating sources of knowledge about operation of the companies look interesting. A total of 97.2% respondents point to one's own experience, 50% of respondents (with the opportunity for multiple choice) point to the role and significance of enhancing knowledge through participation in trade fairs, 31.1% gained significant knowledge resources in the course of university studies, 8.5% as a result of postgraduate studies, and 22.6% by other means. This data confirms an earlier assessment of a certain closed nature of entrepreneurs and employees of medical tourism companies in terms of obtaining knowledge. One's own experience as a source of knowledge is expressly emphasized.

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It is worth referring the author's research to the idea of sustainable development. As seen in the research carried out for the (United Nations, 2016), business leaders throughout present high awareness of possibilities and benefits resulting from implementation of SDGs. As many as 89% of investigated companies’ presidents were convinced that involvement in sustainable development will ensure their real influence on their industry. Whereas 87% of respondents see in them primarily opportunities for further development of their organizations through modification of the companies’ attitude to building social and economic value on the basis of sustainable development. Eight out of ten respondents pointed out that this new approach in business will be a significant distinguishing feature against industry competitors (Accenture, United Nations Global Compact, 2016).

Whereas the studies published in the report on SDGs in practice, carried out among representatives of companies and CSR experts, show that SDGs are the objects of business activity in Polish companies too. Close to 62% of companies that took part in the study are preparing to implement or are in the course of implementation of SDGs, where as many as 85% of investigated CSR practitioners see the opportunities for implementation of SDGs by including them in their CSR strategy, while 68% see it so by including them in their business projects (CSR Consulting, 2016b). The most important benefits of implementing SDGs include greater customer trust (51%), improved reputation (49%), and increase of company value (49%). As for the barriers pointed to by respondents, the following two were the mostly named: too little knowledge about SDGs (56%) and a relatively modest culture of cooperation in implementation of nonbusiness goals (42%). If we compare this research with research conducted by the author, it can be seen that respondents see SDGs as one of more important factors in development since 78% of the investigated individuals responded so. This shows that Polish companies see benefits in implementing sustainable development principles. These results are also reflected in research carried out by a consulting company, i.e., Deloitte—a nationwide ranking among the largest Polish companies that undertake activities in terms of CSR and sustainable development (Rudzki, 2017). Because of this, one can observe relatively low awareness among Polish business leaders as compared to leaders of international companies given certain difficulties in implementing sustainable development issues. Today, companies that take into account environmental and social aspects are considered innovative. The common feature of these companies is the fact that their aim is to achieve profitability by meeting specific needs and achieving a positive impact on the environment and society. Companies’ activities in terms of sustainable development leads to the emergence of new business concepts, such as sustainable entrepreneurship.

In the contemporary age, there is a rapid growth of the role and significance of services. Flat, horizontal, and decentralized structures are emerging increasingly (Borowiecki, Olesiński, 2019, p. 11), which substantiate the validity of creating interorganizational networks and cooperation of often small organizations, including among medical tourism companies.

A direct reason for this development involves an increase in the standard of life that allows collecting funds for esthetic medical procedures. Certain life-style prerequisites—keeping certain discretion about having an esthetic medicine procedure or plastic surgery done—affect the development of a specific type of tourism, i.e., medical tourism. The nature of the services encourages the development of various types of companies, such as limited liability companies, joint-stock companies, or limited companies. Medical tourism companies have a varying number of employees, from micro-, to small-, to medium-sized companies.

As the study shows, relatively young and educated owners and employees of companies in medical tourism do not show greater inclinations to cooperate with organizations from their surroundings, including other companies operating in the discussed industry, medical establishments, or tourism companies. Despite that, it seems reasonable for state and local government authorities to encourage cooperation among these circles and encourage the use of public support.

The analysis of research results shows the reasonable ground for it being continued. It may turn out significant to compare development paths of companies in medical tourism with similar companies in other countries of the European Union.

The study has shown that development of companies in medical tourism is a certain component of metropolises’ sustainable development. It has been demonstrated that a dynamic development of companies occurred in the investigated period, which encourages expansion of medical tourism services among residents of the said metropolises. The study also points to the companies’ appropriate anchoring in medical tourism in their own environment, including in metropolises, which allows a conclusion that these companies constitute a certain element of sustainable development of a metropolis.

When attempting to outline the perspectives for development of the medical tourism sector, it is worth perceiving its future in the context of the development of the services economy, whose one of the elements consists the idea of Industry 4.0 or Economy 4.0 (Gracel, Rodak, 2020; Rauch, Linder, Dallasega, 2020).

The conceptualization and implementation of the idea of sustainable development, which is the frame facilitating the construction of current tasks, is a certain reference point in creating the services economy, aptly specified in quotes from the studies by former US president Barack Obama and included by an outstanding Polish scholar A. Koźmiński in detail, as the author believes, in the tasks for the coming century.

The problems referred to in this paper are a certain fragment heralding the validity of further research of the services sector, including the medical tourism sector in Poland, which deserves further intensive investigation.