Between opportunity and equity: navigating medical tourism in Türkiye’s public hospitals

Abstract

Background

Medical tourism has been proposed as a potential means of using available capacity in public hospitals, generating additional revenue, and supporting healthcare investment. However, public-sector participation also raises concerns regarding organizational readiness, resource allocation, and equitable access for local patients. Türkiye, with its extensive healthcare infrastructure and cost advantages, has become an important medical tourism destination where both public and private hospitals provide services to international patients. This study explored institutional stakeholders’ perspectives on the provision of medical tourism services in Türkiye’s public hospitals.

Method

This study addresses a research gap by providing empirical evidence on medical tourism in public hospitals, a topic that has received limited attention. Focusing on public institutions allows exploration of the tension between economic gains and healthcare equity. A qualitative study was conducted using semi-structured interviews with 13 institutional stakeholders, including Ministry of Health officials, academics, hospital administrators, and medical tourism coordinators. The data were analyzed using inductive qualitative content analysis.

Results

Six interrelated codes were identified: healthcare service quality, access to care, the balance between international and local patients, organizational capacity, financial implications, and equity in service delivery. Participants perceived selected public hospitals, particularly large city hospitals, as having relevant infrastructural and clinical assets. However, readiness was described as heterogeneous and conditional on investment in international outreach, pre-arrival assessment and coordination, trained personnel, translation, travel and accommodation coordination, and post-treatment follow-up. Participants also emphasized risks related to workforce pressure, longer waiting times, preferential access, financial uncertainty, and the possible diversion of resources from local healthcare needs. The study did not establish whether the expected revenues would exceed the full financial and opportunity costs of these investments.

Conclusion

Stakeholders viewed selected public hospitals as possible settings for medical tourism, but physical infrastructure alone was not considered evidence of operational readiness. Public-sector involvement would require hospital-specific assessment of workforce capacity, financing, governance, local patient access, and equity implications. Given the uncertainty surrounding funding sources, net public benefit, and public acceptability, any expansion should be preceded by feasibility, budget-impact, and equity assessments and should initially be considered only in institutions with demonstrable excess capacity.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15636-2.

Introduction

Medical tourism represents a strategic opportunity for countries both economically and socially, owing to its potential to generate foreign exchange revenue, strengthen healthcare infrastructure, and enhance international competitiveness [1, 2]. The inclusion of public hospitals in medical tourism has been proposed as a potential means of generating additional revenue that could, subject to transparent governance and allocation mechanisms, be reinvested in healthcare services. However, such participation also requires initial and recurrent public investment, and the net benefit depends on whether revenues exceed the full costs of attracting and supporting international patients [3]. Beyond the economic gains, this process also bears significance for the equitable allocation of public resources, the enhancement of social welfare, and the sustainability of healthcare services [4].

Medical tourism is considered a rapidly growing sector in both developed and developing countries over the past twenty years. In particular, the integration of public hospitals into medical tourism has emerged as a key topic of discussion in relation to healthcare financing and capacity management in regions such as Southeast Asia, the Middle East, and parts of Europe [1, 5]. Several studies have highlighted that public hospitals are structurally prepared for medical tourism and that reinvesting revenues into service quality can contribute to social welfare [6, 7]. National policies promoting the integration of public hospitals into medical tourism are currently being implemented in countries such as Türkiye, India, Malaysia, and South Africa [2]. However, this process is often challenged by multidimensional constraints such as financial limitations, infrastructural deficiencies, staff shortages, insufficient promotion, and regulatory gaps [3, 8]. Although public hospitals may gain financially from medical tourism, the increased provision of services to foreign patients—if not accompanied by additional resource investments—can prolong waiting times for local patients and jeopardize their welfare [6]. Consequently, issues such as access to care, patient privacy, pricing, and treatment prioritization have triggered ethical debates [1, 9].

Although the existing literature provides insights into the integration of public hospitals into medical tourism, most studies have focused primarily on private institutions. In countries such as Indonesia and South Africa, despite the infrastructural capacity of public hospitals, promotional weaknesses, lack of intersectoral coordination, and regulatory deficiencies have prevented them from realizing their full potential in medical tourism [3, 10]. Similarly, data from a public hospital in Türkiye indicate that international patients predominantly originate from neighboring countries and the diaspora; however, revenue per patient remains below the national average. This suggests that while public hospitals contribute to medical tourism, their economic impact may be more limited than that of private facilities [11].

Research on the performance of public hospitals in meeting international patient expectations remains limited. Existing findings point to financial constraints, long waiting times, and staff shortages as factors that undermine their competitiveness [12]. Moreover, low levels of awareness and readiness among healthcare professionals regarding medical tourism practices may negatively affect service delivery [13]. Additionally, the environmental costs of growing medical tourism—such as medical waste generation and greenhouse gas emissions—have been increasingly emphasized [14].

While the literature has addressed both the opportunities and risks of medical tourism in public hospitals, notable research gaps persist. There is a lack of empirical and comparative studies on the sustainability, social impacts, environmental consequences, and ethical dimensions of medical tourism within public hospitals [9, 15]. Furthermore, the absence of comprehensive policies and standards governing public hospital involvement in medical tourism at both national and international levels continues to be a challenge [8].

Globally, international patient services are predominantly delivered by private providers, which are generally more flexible in responding to patient expectations regarding speed, coordination, accommodation, communication, and personalized services. Public hospitals, by contrast, must balance these expectations with broader obligations related to equitable access, public accountability, workforce allocation, and the protection of domestic healthcare needs. Accordingly, the present study should be interpreted as an exploratory first step in examining a comparatively under-researched public-sector context. Accordingly, this study aims to explore institutional stakeholders’ perspectives on the provision of medical tourism services in public hospitals in Türkiye. Although Türkiye has become an important medical tourism destination due to its healthcare infrastructure and relative cost advantages, the role of public hospitals and the organizational, financial, and equity-related implications of their participation have received limited scholarly attention [11]. Drawing on the perspectives and experiences of Ministry officials, hospital administrators, academics, physicians, and medical tourism coordinators, the study examines how selected institutional stakeholders perceive the opportunities, constraints, and conditions associated with medical tourism in public hospitals. The analysis focuses on healthcare service quality, access to care, the balance between international and local patients, organizational capacity, financial implications, and equity in service delivery. By focusing on state-funded institutions, the study considers the tension between revenue-generation objectives and the responsibility to protect equitable access for local populations. Rather than assessing the objective readiness or performance of the public hospital sector as a whole, the study provides an exploratory and context-specific account of stakeholder perceptions and identifies issues that should be examined in future hospital-level feasibility, financial, and equity assessments.

Medical tourism in public hospitals in Türkiye

The global medical tourism market has grown rapidly in recent years, driven by factors such as cost advantages, advanced technology, and the availability of specialized physicians, which encourage patients to seek treatment abroad. In this context, Türkiye’s market share in medical tourism has also expanded; between 2012 and 2024, the number of medical tourists visiting the country increased sixfold, reaching approximately 1.5 million individuals, while healthcare service exports rose to around 3 billion USD [16]. This growth has led public hospitals to engage in medical tourism activities due to the need for additional financial resources, the desire to utilize idle capacity, and the goal of enhancing international patient satisfaction.

As of the end of 2023, there were a total of 1,566 hospitals in Türkiye, of which 933 were public hospitals, 68 were university hospitals, and 565 were private hospitals. Therefore, with a share of approximately 64%, public hospitals form the main backbone of healthcare service delivery. Among these, there are training and research hospitals, specialty hospitals, and an increasing number of city hospitals [17]. City hospitals are large healthcare campuses built under the public–private partnership model. The first city hospital was inaugurated in 2016, and by the end of 2024, 25 city hospitals were operational, with additional facilities under construction across various provinces [18]. Designed to serve both local patients and medical tourists, these hospitals feature modern infrastructure, high bed capacity, advanced diagnostic and treatment facilities, and hotel-like accommodation services. In addition to city hospitals, university hospitals and training and research hospitals in Türkiye also provide medical tourism services [19].

Türkiye has established a comprehensive legal framework regulating medical tourism activities in both public and private hospitals. Over the years, several legislative arrangements have been introduced, the most recent being the Regulation on International Medical Tourism and Tourist Health, enacted in 2025. This regulation was designed to define minimum service standards for all sectoral stakeholders, authorize healthcare and intermediary institutions, and oversee their operations. It covers both public and private healthcare facilities, setting out the rules for admitting international patients. Hospitals must obtain an International Medical Tourism Authorization Certificate issued by the Ministry of Health to operate in this field. Within this framework, hospitals are required to establish an International Patient Unit, employ at least one staff member proficient in a foreign language, comply with the quality standards of the Turkish Health Care Quality and Accreditation Institute (THCQAI), and adhere to the price tariffs announced by the Ministry. Thus, the regulatory framework is intended to establish minimum standards and promote quality, reliability, and transparency; however, its effectiveness depends on implementation, monitoring, and enforcement. As of 2025, approximately one-third of the hospitals holding an International Medical Tourism Authorization Certificate were public institutions [20].

By 2024, the number of patients visiting Türkiye for medical tourism purposes had reached approximately 1.5 million [21]. Although public hospitals in Türkiye possess strong infrastructural capacities to support medical tourism, it has been reported that many international patients tend to prefer private hospitals due to various reasons, including shorter waiting times, customized services, and perceived comfort [19].

Methods

Aim

This study aimed to explore institutional stakeholders’ perspectives on the provision of medical tourism services in public hospitals in Türkiye, with particular attention to organizational capacity, access, financial implications, and equity in service delivery.

Study design

This study employed a qualitative research design to examine how institutional stakeholders perceive the opportunities, constraints, and implications associated with medical tourism in Türkiye’s public hospitals. A qualitative approach was selected because it allows an in-depth exploration of complex organizational, managerial, and ethical issues through participants’ experiences and interpretations [22]. Semi-structured, in-depth interviews were used as the primary data collection method, providing a consistent framework while allowing participants to elaborate on context-specific issues relevant to the study objectives.

Participants

Purposive sampling was used to recruit participants who were expected to provide relevant and information-rich perspectives on medical tourism in public hospitals [23]. Participants were selected on the basis of their institutional, managerial, clinical, academic, policy-related, or coordination experience relevant to medical tourism. The sample included chief physicians and other hospital administrators, Ministry of Health officials responsible for medical tourism, academics working in related fields, physicians, and coordinators or staff members of international patient and medical tourism units in public hospitals. Participants’ exposure to medical tourism varied: some had direct operational or managerial experience with international patient services, whereas others contributed clinical, academic, training, or policy perspectives. A total of 13 participants (P1–P13) were recruited through purposive and snowball sampling. The sample was designed to capture a range of institutional and managerial perspectives, including those of Ministry officials, academics, hospital administrators, physicians, and medical tourism coordinators. The final sample size was determined by the scope and information power of the study and by the recurrence of major issues across interviews. However, because frontline healthcare workers and patients were not included, the study does not claim comprehensive saturation across all stakeholder groups affected by medical tourism. Data were collected using a semi-structured interview form, which ensured both consistency across interviews and the flexibility to explore context-specific issues in greater depth [24]. The interviews were conducted by three researchers between April and July 2025 in Türkiye, a multi-researcher approach that contributed to the credibility and trustworthiness of the data collection process. Table 1 presents descriptive information on the interviewees, such as age, educational background, and experience in the medical tourism sector.

Table 1.

Descriptive characteristics of participants

Name	Age	Gender	Education Level	Graduate Field	Occupation	Years in Medical Tourism	Roles Held in Medical Tourism	Management Experience in Medical Tourism Sector
P1	30–39 years	Male	PhD	Health Tourism	Health Officer	≥ 10 years	Administration	Yes
P2	40–49 years	Male	Medical Doctor	-	Physician	0–4 years	Coordinator	No
P3	≥ 50 years	Female	Dentist	-	Dentist	5–9 years	Coordinator	No
P4	30–39 years	Female	PhD	Health Management	Academic	0–4 years	Researcher & Trainer	No
P5	≥ 50 years	Male	Master’s	Health Management	Health Manager	5–9 years	Administration	Yes
P6	≥ 50 years	Male	PhD	Health Management	Academic	≥ 10 years	Researcher & Trainer	No
P7	30–39 years	Male	Master’s	Business	Health Manager	≥ 10 years	Administration	Yes
P8	30–39 years	Male	Master’s	International Relations	International Relations Specialist	5–9 years	Administration	Yes
P9	40–49 years	Female	Master’s	Health Tourism	Radiotherapist	5–9 years	Coordinator	Yes
P10	40–49 years	Male	Master’s	Business	Health Officer	≥ 10 years	Researcher & Trainer	Yes
P11	40–49 years	Male	Medical Doctor	-	Physician	5–9 years	Administration	Yes
P12	40–49 years	Female	Medical Doctor	-	Physician	5–9 years	Coordinator	Yes
P13	30–39 years	Male	Master’s	Business	Health Tourism Staff	5–9 years	Staff	No

Data collection

Data were collected through a semi-structured interview form (Appendix 1), developed in accordance with the study’s objectives. The form included two main sections: (1) sociodemographic characteristics of the participants, and (2) open-ended questions focusing on the outcomes and implications of medical tourism practices in public hospitals. Open-ended questions were determined by reviewing the literature [3, 5, 6, 25]. Prior to initiating the study, the interview form was subjected to expert review in order to ensure the clarity, comprehensibility, and content relevance of the questions. For this purpose, feedback was obtained from five academics who have conducted scholarly research in the field of medical tourism. Based on the suggestions received, necessary revisions were made to the questions to enhance their validity and appropriateness for the research context.

Participation was voluntary, and informed consent was obtained from all participants. Face-to-face interviews were conducted in a private setting convenient for the participants, each lasting approximately 30–45 min. With participants’ permission, interviews were audio-recorded and supplemented with field notes. In cases where audio recording was declined, comprehensive written notes were taken. All data were transcribed verbatim and anonymized to ensure confidentiality.

Data analysis

The interview transcripts were analyzed using inductive qualitative content analysis, following the procedures described by Elo and Kyngäs [26]. The transcripts were read repeatedly to obtain an overall understanding of the data, after which meaning units relevant to the research aim were identified and assigned open codes. Conceptually similar codes were compared and grouped into categories, and categories sharing common meanings were iteratively abstracted into broader theme. Coding decisions, categories, and theme were repeatedly reviewed against the original transcripts, and disagreements within the research team were resolved through discussion and consensus.

Microsoft Excel was used to organize the transcripts, coded meaning units, codes, and categories and to support the manual coding process. R software was used only for data management, word-frequency summaries, and descriptive visualizations, including the word clouds. Neither the R outputs nor the word-frequency results were used to generate codes, categories, or theme. After the inductive analysis and theme development had been completed, coded meaning units within each code were secondarily classified as positive, negative, or conditional to provide a descriptive overview of the orientation of the accounts. The resulting frequencies refer to coded meaning units rather than participants; an individual participant could contribute more than one meaning unit within or across theme. These frequencies were not used to estimate prevalence, rank thematic importance, make inferential comparisons, or draw substantive conclusions. Interpretation was based primarily on the content and context of participants’ accounts, the relationships among categories and codes, and representative quotations.

To strengthen the trustworthiness of the analysis, coding was independently reviewed by multiple researchers. Discrepancies were resolved through discussion and consensus. Direct quotations were incorporated into the findings to preserve participants’ voices and enhance credibility [27].

Trustworthiness, validity and reliability

To ensure the rigor of this qualitative study, we followed the criteria of trustworthiness as defined by Lincoln and Guba [28], namely credibility, transferability, dependability, and confirmability, alongside broader considerations of validity and reliability [29]. Credibility was strengthened through triangulation in coding, involvement of multiple researchers in data analysis, and the inclusion of direct participant quotations to substantiate the codes. Transferability was supported by providing thick descriptions of the research context and participant characteristics. Dependability was addressed by maintaining an audit trail of methodological decisions and ensuring consistency in coding and theme development across analysts. Confirmability was enhanced through reflexivity and transparent reporting of analytic procedures. In addition, concerns of validity and reliability were addressed by cross-checking interview transcripts and codes among the research team, triangulating primary and secondary sources of data, and presenting both positive and negative cases, thereby reducing potential researcher bias and enhancing the robustness of the findings.

Results

Inductive qualitative content analysis identified six interrelated codes concerning medical tourism in Türkiye’s public hospitals: healthcare service quality, access to services, the balance between international and local patients, organizational capacity, financial implications, and equity in service delivery. These codes were developed by grouping conceptually related meaning units derived from participants’ accounts and are presented in Fig. 1.

Fig. 1.

Main theme and basic codes of the study

The findings indicate that participants did not view public hospital involvement in medical tourism in uniformly positive or negative terms. Instead, their accounts were frequently conditional and context-dependent, reflecting concerns about hospital capacity, workforce availability, governance, financing, and the protection of local patient access. For descriptive purposes, coded meaning units were subsequently classified as positive, negative, or conditional; however, these categories were used only to summarize the orientation of participants’ views and did not constitute the analytical framework of the study.

To facilitate the presentation of the findings, participants’ views within each code were descriptively summarized according to their overall orientation (positive, negative, or conditional). These categories were generated after theme development and are intended only to provide an overview of the distribution of perspectives rather than to represent the coding framework.

The findings were not uniformly positive or negative; participants’ accounts were frequently conditional and context-dependent. After the six codes had been developed through inductive qualitative content analysis, coded meaning units within each code were secondarily classified as positive, negative, or conditional for descriptive presentation. Table 2 reports the distribution of these orientations. The counts refer to coded meaning units rather than individual participants, and a participant could contribute multiple meaning units within or across codes. The frequencies were not used to construct the codes, determine their relative importance, estimate the prevalence of particular views, or support inferential conclusions. Accordingly, Table 2 should be interpreted as a supplementary descriptive overview, while the thematic narratives and participant quotations constitute the primary presentation of the findings. Detailed views of the codes and subcodes are presented in the figures below (Figs. 2, 3, 4, 5, 6 and 7).

Table 2.

Descriptive distribution of coded meaning units by orientations

Codes	Positive	Negative	Conditional	Total
Quality of Healthcare Services	6	3	26	35
Access to Services	9	10	19	38
Balance Between Medical Tourists and Local Patients	6	4	12	22
Organizational Capacity	16	5	15	36
Financial Benefit	11	3	19	33
Equity in Service Delivery	5	4	6	15

Note: Counts refer to coded meaning units, not individual participants; the same participant could contribute more than one meaning unit within or across codes. The positive, negative, and conditional classifications were assigned only after completion of the inductive qualitative content analysis. They were used solely to provide a supplementary descriptive overview and did not guide code generation, category development, or theme construction. The frequencies should not be interpreted as estimates of prevalence, indicators of thematic importance, or a basis for inferential comparison

Fig. 2.

Code cloud of quality of healthcare services

Fig. 3.

Code cloud of access to services

Fig. 4.

Code cloud of balance between medical tourists and local patients

Fig. 5.

Organizational capacity

Fig. 6.

Code cloud of financial benefit

Fig. 7.

Code cloud of equity in service delivery

Quality of healthcare services

Positive accounts of healthcare service quality focused on participants’ confidence in the clinical competence of public hospitals, particularly physicians’ expertise, evidence-based decision-making, and adherence to standardized treatment protocols. Participants generally distinguished the quality of clinical care from limitations in access and service organization. P3 illustrated this qualified confidence by explaining, “In other words, they really do an excellent job. Whether it’s diagnosing patients, providing treatment, or following protocols, they adhere to the latest approaches in all these areas. I’ve seen the quality of healthcare firsthand and I appreciate it. The only issue is that access to them is somewhat limited. You don’t get to see the doctor as often, nurses are so busy that they can’t check on you as frequently, and there can be wait times for imaging services. But when evaluated purely in terms of healthcare services, I think public hospitals are quite successful.”

Negative accounts focused less on clinical competence itself than on whether existing quality standards could be sustained under increasing service pressure. Participants identified high patient volumes, workforce limitations, reduced contact with healthcare professionals, and delays in diagnostic services as factors that could weaken the patient experience and eventually affect service quality. P5 explained, “The medical care is good. It’s just that they can’t keep up due to the high volume of patients. Patients may encounter some issues caused by this high volume. Other than that, the service is quite good.” These accounts therefore distinguished the underlying quality of clinical care from hospitals’ capacity to deliver that care consistently under conditions of high demand.

Conditional accounts emphasized that the effect of medical tourism on service quality would depend on organizational planning, regulatory oversight, and the distinction between clinical and hospitality-related aspects of care. P6 stated, “The clinical care itself is generally delivered according to high standards. What patients often perceive as poor quality is actually related to waiting times, registration procedures, communication, and other non-clinical services. Therefore, the distinction should be made between medical quality and hospitality-related service quality.” Overall, participants did not regard medical tourism as inherently improving or reducing healthcare quality; they viewed its effects as dependent on whether clinical standards could be supported by adequate workforce capacity and well-organized service processes. Figure 2 summarizes these positive, negative, and conditional accounts.

Access to services

Positive accounts of access to services emphasized that medical tourism could encourage investment in physical infrastructure, administrative efficiency, and service organization. Participants suggested that improvements initially introduced for international patients could also contribute to the general functioning of public hospitals. P7 stated, “Single-patient rooms, faster administrative procedures, and more accessible service delivery would benefit not only international patients but also improve the overall functioning of the hospital.”

Negative accounts focused on the possibility that international patient demand could intensify existing access problems if service capacity did not expand proportionately. Participants identified longer waiting times, reduced appointment availability, workforce shortages, and increased competition for specialist services as potential risks for local patients. P12 explained, “The priority should always be to ensure that local patients are not disadvantaged. If medical tourism expands without increasing service capacity, waiting times may become longer, and this could create inequalities in access to healthcare.” Participants consequently described access as both an operational and an ethical concern.

Conditional accounts emphasized that the effect of medical tourism on access would vary according to existing hospital workload, regional demand, workforce availability, and the extent of capacity expansion. P11 stated, “Even under current conditions, hospitals experience considerable pressure due to high patient volumes. If additional international patients are accepted without expanding infrastructure and workforce capacity, accessibility problems may become more pronounced for everyone.” Overall, participants did not regard improved access as an automatic consequence of medical tourism. They considered it a conditional outcome requiring adequate infrastructure, workforce planning, and protection of existing service capacity. Figure 3 summarizes these positive, negative, and conditional accounts.

Balance between medical tourists and local patients

Positive accounts suggested that international and local patients could be served within the same public hospital system if clear capacity-allocation mechanisms were established. Participants proposed quotas, designated service areas, and separate patient pathways as possible ways of preventing international patient services from disrupting routine care. P5 explained, “Fairness can be maintained if clear quota systems are established. A certain proportion of appointments can be reserved for international patients while ensuring that local patients continue to receive timely access to healthcare services.”

Negative accounts focused on the risk that international patients might receive faster or preferential access to appointments and experienced clinicians. Participants warned that both actual and perceived preferential treatment could undermine local patients’ confidence in publicly funded healthcare institutions. P12 stated, “If international patients are consistently treated more quickly or appear to receive preferential access to physicians, local patients may inevitably perceive this as unfair. Even if the actual clinical quality remains unchanged, the perception of unequal access may damage trust in public healthcare services.”

Conditional accounts emphasized that the balance between patient groups would depend on hospital capacity, workforce availability, transparent communication, and regulatory oversight. P9 explained, “Maintaining a balance between local and international patients is possible, but only if the hospital has sufficient physical capacity, workforce, and organizational planning. Otherwise, both patient groups may experience dissatisfaction.” Participants therefore described balance as a feasible but fragile outcome rather than an automatic consequence of expanding medical tourism. Figure 4 summarizes these positive, negative, and conditional accounts.

Organizational capacity

Positive accounts of organizational capacity focused on the advanced facilities and equipment available in selected public hospitals, the experience gained by staff from managing high patient volumes, and the physical and technological capacity of city hospitals. Participants did not, however, extend this assessment to all public hospitals. As P7 explained, “City hospitals possess the technological infrastructure, physical capacity, and multidisciplinary workforce required for international patient services. Therefore, if medical tourism is to be expanded within the public sector, city hospitals should be the primary institutions responsible for delivering these services.”

Negative accounts distinguished physical infrastructure from operational readiness. Participants identified administrative rigidity, slow decision-making, workforce limitations, and the absence of dedicated units and trained personnel as barriers to managing international patients. P12 stated, “Providing treatment alone is not sufficient. International patients require appointment coordination, visa support, accommodation, transportation, translation services, and continuous communication throughout the treatment process. Public hospitals often experience difficulties coordinating these services because they lack dedicated organizational units and specialized personnel.”

Conditional accounts emphasized that organizational readiness varied considerably between institutions and depended on hospital size, regional demand, managerial capacity, workforce availability, and technological resources. P6 noted, “It would not be appropriate to evaluate all public hospitals using the same criteria. Large city hospitals generally possess stronger infrastructure and organizational capacity, whereas smaller provincial hospitals often face limitations in terms of workforce, technology, and managerial resources. Therefore, organizational readiness should be assessed individually for each institution.” Overall, participants described hospital-specific and developable capacity rather than uniform readiness across the public hospital system. Figure 5 summarizes these positive, negative, and conditional accounts.

Financial benefit

Positive accounts emphasized that revenues from medical tourism could reduce public hospitals’ dependence on central budgets, support reinvestment in infrastructure and medical technologies, and provide financial incentives for healthcare personnel. P1 stated, “The revenue generated from medical tourism could reduce dependence on the central government budget and provide hospitals with greater financial flexibility. These additional resources could be reinvested in new medical technologies, infrastructure improvements, and service quality, ultimately benefiting both international and local patients.”

Negative accounts focused on the distributional and ethical risks associated with financial incentives. Participants warned that concentrating additional income in particular departments or among selected professionals could create dissatisfaction, weaken teamwork, and allow financial considerations to influence institutional or clinical priorities. P12 explained, “If the income generated through medical tourism benefits only certain departments or specific professionals, this may create dissatisfaction among other employees, reduce teamwork, and eventually disrupt the organizational climate.”

Conditional accounts emphasized that financial benefits would not arise automatically and would depend on transparent revenue-allocation rules, appropriate legal regulation, stable international patient demand, and a balance between institutional investment and workforce expectations. P6 stated, “Medical tourism certainly has the potential to generate additional income for public hospitals. However, unless there are clear legal regulations defining how these revenues will be allocated and utilized, financial gains may not produce the expected institutional benefits.” Participants therefore regarded financial benefit as a conditional possibility rather than a guaranteed outcome. Figure 6 summarizes these positive, negative, and conditional accounts.

Equity in service delivery

Positive accounts did not suggest that equity would be preserved automatically. Rather, participants considered equitable service delivery possible when local patient capacity was protected through quota systems, transparent patient-allocation rules, and limits on physician workload. P5 explained, “Each physician should have a clearly defined quota for international patients. Such an arrangement would allow hospitals to provide medical tourism services while ensuring that local patients continue to receive healthcare without unnecessary delays or disadvantages.”

Negative accounts focused on the possibility that international patient services could intensify existing inequalities when hospital resources were already limited. Participants raised concerns about longer waiting times, reduced appointment availability, and restricted access to experienced clinicians for local patients. P3 stated, “In some regions, patients already experience long waiting times for appointments and elective procedures. If international patients are admitted without increasing hospital capacity, local residents may face even greater difficulties accessing healthcare services. Under such circumstances, protecting equity becomes increasingly challenging.” Participants also warned that staff and investment could gradually shift toward hospitals and services generating higher financial returns.

Conditional accounts framed equity as a fragile outcome requiring continuous oversight rather than a condition that could be secured through a single regulation. P8 emphasized that “Public hospitals inevitably need additional financial resources, but revenue generation should never become more important than their primary responsibility to provide equitable healthcare. Maintaining this balance requires constant supervision and transparent governance.” Participants consequently regarded quotas, separate patient pathways, workload limits, and revenue-allocation rules as potential safeguards whose effects would need to be monitored over time. Figure 7 summarizes these positive, negative, and conditional accounts.

Discussion

The findings suggest that healthcare service quality was understood as a multidimensional concept. Participants generally expressed confidence in the clinical competence of public hospitals and associated quality with professional expertise, evidence-based decision-making, standardized treatment protocols, and technological capacity. This interpretation is consistent with previous research emphasizing the importance of uniform clinical standards and accumulated professional experience in improving healthcare outcomes [30, 31]. Investment in human and technological resources may similarly strengthen service reliability and institutional capacity [32].However, participants distinguished clinical competence from hospitals’ ability to sustain high-quality service under conditions of increasing demand. High patient volumes, workforce limitations, reduced contact with healthcare professionals, and delays in diagnostic services were identified as potential threats to the consistency of care. These concerns suggest that medical tourism could place additional pressure on existing services when international patient demand is not accompanied by proportional investment in staffing and capacity. They are also consistent with literature emphasizing the importance of patient-centred service organization, equitable resource allocation, and continuing professional development in maintaining healthcare quality [33–35].

The conditional accounts further demonstrate the importance of distinguishing clinical quality from hospitality-related service quality. Waiting times, registration processes, communication, coordination, and other non-clinical services may shape patients’ perceptions even where clinical standards remain high [36]. Medical tourism should therefore not be assumed either to improve or to diminish quality automatically. Its effects are likely to depend on regulatory frameworks, capacity planning, and governance mechanisms capable of preserving clinical standards while preventing prioritization and equity problems [37, 38].

The findings indicate that medical tourism may create opportunities to improve access through investment in infrastructure, administrative processes, and service organization. Where additional resources expand overall hospital capacity, improvements introduced for international patients may also benefit local service users. This interpretation is consistent with research suggesting that expanded capacity, decentralized service delivery, and improved organizational processes can strengthen access to healthcare [39, 40]. Nevertheless, the findings also demonstrate that accessibility varies across institutions and regions and cannot be inferred from investment alone.

The principal risk arises when international patient demand increases without corresponding growth in workforce and service capacity. Under these circumstances, medical tourism may prolong waiting times, reduce appointment availability, and intensify competition for specialist services. Such effects would be especially important in public hospitals already operating under substantial demand. Previous research has similarly warned that prioritizing non-resident or higher-paying patients may disadvantage local populations [41] and has identified workforce shortages, waiting times, transportation difficulties, and administrative complexity as persistent barriers to equitable access [42, 43].

Access should therefore be treated as a capacity-dependent outcome rather than as an inherent benefit of medical tourism. The relevant question is whether hospitals can create additional service opportunities without reducing the availability or timeliness of care for local patients [44]. This requires hospital-specific assessment of existing workloads, workforce availability, regional demand, and the resources needed to support international patient services. Monitoring changes in waiting times, appointment availability, and access to specialist care would be necessary before interpreting service expansion as an improvement in accessibility [45, 46].The findings suggest that participants did not regard competition between international and local patients as inevitable. Quota systems, designated service areas, separate patient pathways, and transparent capacity-allocation rules were considered possible mechanisms for allowing the two groups to be served within the same public hospital system. These perspectives are consistent with literature suggesting that regulatory frameworks and carefully managed hospital capacity may support the coexistence of domestic and international services [47–50]. However, the proposed mechanisms represent governance options rather than measures whose effectiveness was evaluated in the present study.The principal concern was that actual or perceived preferential access for international patients could delay local care and weaken public trust. This distinction is important because perceptions of unfairness may damage confidence in public healthcare even when formal clinical standards remain unchanged. Previous studies have similarly associated preferential resource allocation to higher-paying patients with longer waiting times and perceptions of inequity among local populations [51, 52]. Such arrangements may also conflict with the equal-access principles underlying publicly funded healthcare systems [53]. The balance between patient groups should therefore be interpreted as a conditional and potentially unstable outcome. It depends not only on physical capacity and workforce availability but also on transparent communication, institutional governance, and public perceptions of fairness [5, 54–56]. International experience further suggests that parallel service arrangements do not produce uniform results across healthcare systems; their effects vary according to resource availability and regulatory capacity [57–59]. Public hospitals would therefore need to monitor appointment allocation, waiting times, staff distribution, and patient experiences to determine whether organizational safeguards are protecting local access in practice.

The findings indicate that the organizational capacity of public hospitals for medical tourism cannot be assessed solely on the basis of physical infrastructure. Advanced facilities, technological equipment, clinical expertise, and experience in managing high patient volumes were perceived as important institutional assets. This finding is consistent with previous research identifying infrastructure and clinical expertise as key determinants in attracting international patients [60, 61] and showing that international patients generally prefer hospitals with advanced technology, modern facilities, and experienced healthcare professionals [3, 6, 12]. Nevertheless, the findings do not support the assumption that all public hospitals are equally prepared to provide medical tourism services. Instead, they point to the need for selective, hospital-specific assessments of infrastructure, workforce capacity, managerial capability, and the availability of excess service capacity. This interpretation is consistent with Heung et al. [62], who argued that public-sector medical tourism is more likely to succeed when provided through dedicated and appropriately equipped facilities rather than being introduced indiscriminately across existing public hospitals.

A central finding was the distinction between internal clinical capacity and broader operational readiness. Although selected public hospitals may possess strong infrastructure and qualified healthcare professionals, administrative rigidity, slow decision-making, workforce limitations, and the absence of dedicated organizational units may restrict their ability to respond effectively to the expectations of international patients. Organizational readiness therefore extends beyond beds, equipment, and clinical personnel. It also encompasses international outreach, responses to initial inquiries, remote assessment of medical documentation, preparation of treatment and price information, appointment coordination, multilingual communication, visa and travel support, accommodation and transportation arrangements, translation, and post-treatment follow-up. This broader interpretation accords with literature emphasizing that sustainable medical tourism requires the coordination of both clinical and non-clinical services across the international patient pathway [6, 60, 61, 63].

The findings further suggest that organizational capacity is context-dependent and dynamic rather than a uniform or fixed characteristic of Türkiye’s public hospital system. Differences in hospital size, regional healthcare demand, workforce availability, technological resources, and managerial capacity mean that some institutions may be comparatively prepared to provide international patient services, whereas others may require organizational restructuring, specialized personnel, and broader capacity development. Accordingly, organizational readiness should be evaluated not only in relation to hospitals’ current resources but also in terms of their potential for institutional development. A phased approach beginning with hospitals that demonstrate sufficient capacity and operational preparedness may therefore be more appropriate than system-wide expansion. Such an approach would also allow organizational models and coordination mechanisms to be evaluated before services are expanded, while reducing the risk of compromising routine healthcare delivery for local patients.

The findings suggest that the potential financial contribution of medical tourism was understood as extending beyond immediate revenue generation. If transparently managed and appropriately reinvested, additional revenues could support infrastructure improvements, technological modernization, service quality, workforce development, and the longer-term financial sustainability of public hospitals. This expectation is consistent with previous research indicating that hospitals participating in medical tourism may use additional revenue streams to invest in advanced medical technologies, modern facilities, and service improvements [64]. Enhanced financial capacity may also contribute to professional development and institutional competitiveness in international healthcare markets [65]. However, the benefits identified in the present study represent stakeholders’ expectations rather than evidence of actual financial performance. The study did not examine hospital financial records or determine whether revenues from international patients are currently reinvested in public services or distributed in the ways anticipated by participants.

The findings also draw attention to the distributional and ethical risks associated with revenue generation in publicly funded hospitals. Financial benefits concentrated in particular departments or among selected healthcare professionals could create dissatisfaction, weaken organizational cohesion, and generate inequalities within the workforce. Moreover, if revenues from international patients become increasingly important to institutional budgets, financial considerations may gradually influence clinical priorities, resource allocation, and investment decisions. Dependence on international patient demand may create an additional source of uncertainty because fluctuations in patient volume could disrupt revenue projections and long-term financial planning. Financial sustainability therefore depends not only on generating income but also on transparent governance, equitable revenue-sharing arrangements, clear legal regulations, and safeguards ensuring that financial incentives do not displace the public-service responsibilities of hospitals. These concerns are consistent with literature describing potential tensions between commercial objectives, distributive justice, public interest, and equitable healthcare provision [6, 41, 62].

Crucially, the financial feasibility of medical tourism cannot be determined from gross revenue alone. International promotion, dedicated personnel, staff training, multilingual communication systems, translation, digital communication, travel and transport coordination, accommodation support, and post-treatment follow-up would generate both start-up and recurrent costs before any net financial benefit could be established. These functions might be financed through existing institutional budgets, central government allocations, revolving funds, or partnerships with intermediary organizations, each of which raises different governance and accountability considerations. Investment in international patient services also entails an opportunity cost because the same public resources could alternatively be used to reduce waiting times, recruit healthcare personnel, expand domestic service capacity, or improve access in underserved regions. A comprehensive financial assessment would therefore require net-cost and budget-impact analyses, consideration of demand volatility, and comparison with alternative uses of public funds. The anticipated financial benefits should consequently be interpreted as conditional propositions requiring empirical evaluation rather than as demonstrated institutional or public gains.

The findings position equity as a precondition for, rather than an automatic consequence of, public-sector participation in medical tourism. The possibility of serving international patients without disadvantaging local populations was considered dependent on safeguards such as quota systems, transparent patient-allocation rules, physician workload limits, prior capacity assessment, and the protection of domestic appointment availability. This interpretation is consistent with Heung et al. [60], who suggested that selected public hospitals may participate in medical tourism while maintaining their responsibility toward local populations, provided that domestic access is demonstrably protected. However, the safeguards identified in the present study represent proposed governance mechanisms rather than empirically validated solutions. The study did not determine whether such measures would be implemented consistently, prevent longer waiting times, preserve access to experienced clinicians, or operate effectively under changing service pressures.

The findings also indicate that the equity implications of medical tourism extend beyond individual encounters between local and international patients. Where hospital capacity is already constrained, the allocation of appointments, specialist time, and other finite resources to international patients may increase waiting times and reduce timely access for local populations. These concerns are consistent with previous studies suggesting that the commercialization of healthcare through medical tourism may challenge distributive justice and equitable access in public health systems [1, 19]. Pirzada [66] similarly highlighted the potential for inequalities between international and domestic patients, while Yılmaz and Aktaş [19] argued that public hospitals should prioritize local healthcare needs and participate in medical tourism only where adequate excess capacity is available. Potential effects may also emerge at the broader health-system level. If medical tourism becomes financially more attractive in particular institutions or clinical specialties, experienced healthcare professionals, investment, and managerial attention may gradually shift toward well-resourced metropolitan hospitals and highly profitable tertiary services. Such developments could deepen existing disparities between institutions and regions and divert resources from services primarily needed by local populations. Previous research has similarly warned that medical tourism may contribute to workforce redistribution, rising healthcare costs, and the concentration of investment in profitable specialized services at the expense of broader population health needs [60, 67–69]. Dürüstkan [9] also identified ethical tensions involving pricing, distributive justice, public interest, and the institutional responsibilities of public hospitals.

Equity should therefore be regarded as a dynamic governance outcome requiring continuous assessment rather than as a condition secured permanently through a single regulation or organizational arrangement. Safeguards such as quotas, separate patient pathways, workload limits, and revenue-allocation rules may become ineffective if they are not regularly reviewed against actual service outcomes. Monitoring should include local waiting times, appointment availability, staff allocation, access to experienced clinicians, and differences in service experience between local and international patients. Financial incentives and dependence on international patient revenues should also be examined because they may gradually reshape institutional priorities even when formal policies continue to endorse equal access. The literature has described this potential shift toward commercial priorities within formally public institutions as a form of “backdoor privatization” [9, 19, 70]. This concept should be understood as a theoretical and policy concern derived from previous research rather than as terminology used by participants in the present study.

The public acceptability of the investments and organizational arrangements required to protect equity also remains uncertain. Transparent reinvestment of revenues in services benefiting the wider population may strengthen perceptions of fairness. Conversely, expenditure on international promotion, dedicated personnel, translation, transport, accommodation support, or separate service pathways may be viewed as inequitable where local patients continue to experience staff shortages, delayed appointments, or unmet healthcare needs. Because local patients and members of the public were not included in the sample, the present study cannot determine how these investments would be perceived. Future research should therefore directly examine public and patient perspectives on the fairness and legitimacy of allocating public resources to international patient services before large-scale implementation.

Conclusion

This study explored the perspectives of 13 institutional stakeholders regarding medical tourism in Türkiye’s public hospitals. Participants identified modern infrastructure, advanced technology, and clinical experience as possible assets in selected institutions, particularly large city hospitals. However, these assets do not establish that public hospitals are fully prepared to deliver medical tourism services. Operational readiness would require investment in international promotion, pre-arrival assessment and communication, trained personnel, translation, travel and accommodation coordination, and post-treatment follow-up. The feasibility of such investment remains uncertain because its funding sources, net financial returns, opportunity costs, and public acceptability were not assessed. The findings therefore support cautious, hospital-specific evaluation rather than a general conclusion that the public hospital sector has substantial potential.

Policy and strategic recommendations

Before expanding medical tourism in public hospitals, the Ministry of Health should require hospital-specific feasibility assessments covering clinical capacity, workforce availability, domestic waiting times, pre-arrival and post-treatment service requirements, start-up and recurrent costs, expected net revenue, and equity implications. Pilot implementation should be limited to institutions with demonstrable excess capacity and should include predefined indicators for local patient access, staff workload, financial performance, and public benefit. Decisions on expansion should be based on transparent evaluation rather than assumptions that existing infrastructure will automatically translate into operational or financial readiness.

Ethical and justice-based recommendations

Quota systems, separate service pathways, and regulatory standards may provide safeguards, but they should not be assumed to guarantee equity. Their effects should be monitored through local waiting times, appointment availability, staff allocation, access to senior clinicians, and patient experience. Transparency is also required regarding the amount of public investment committed to international patient services and how any resulting revenue is used. Equity should therefore be treated as an outcome requiring continuous measurement and public accountability rather than as an automatic consequence of regulation.

Organizational and operational recommendations

Organizational planning should cover the entire international patient pathway, beginning with international outreach and the first patient inquiry. Required functions include multilingual communication, remote review of medical documentation, treatment and price information, travel and visa coordination, support for accompanying family members, translation, accommodation and transport arrangements, hospital admission, treatment coordination, discharge planning, and follow-up. Before creating or expanding these services, hospitals should identify the additional workforce, training, technology, and financial resources required. Such services should initially be developed only in selected institutions where both clinical capacity and the ability to protect domestic access can be demonstrated. Expansion to other hospitals should not be recommended until pilot programs have been independently evaluated.

Limitations and suggesting future research directions

This study provides an exploratory account of institutional stakeholders’ perspectives on medical tourism in Türkiye’s public hospitals; however, several limitations should be considered when interpreting the findings. First, the study employed a qualitative design with a relatively small and purposively selected sample of 13 participants. Although this sample enabled in-depth exploration of managerial and institutional perspectives, the findings should not be interpreted as representative of all public hospitals or of the broader healthcare system. In particular, the sample primarily consisted of individuals working in management, coordination, academic, and administrative roles. Frontline healthcare professionals, local patients, international patients, members of the general public, and health-finance decision-makers were not included. This limits the extent to which the study can address the operational realities, patient experiences, public acceptability, and equity implications of medical tourism.

Second, the study examined stakeholder perceptions rather than objective indicators of hospital performance or readiness. No comparative data were collected on clinical outcomes, waiting times, patient satisfaction, staffing levels, service quality, institutional costs, or revenues in public and private hospitals. Therefore, statements regarding infrastructure, clinical competence, financial benefits, or organizational readiness should be interpreted as stakeholder views rather than verified institutional outcomes. Future studies should combine qualitative evidence with hospital-level performance data and compare public and private institutions across commonly sought treatments.

Third, the study did not examine the financial feasibility of expanding medical tourism services in public hospitals. No data were available on the start-up and recurrent costs of international promotion, dedicated staffing, staff training, translation, pre-arrival communication, visa and travel coordination, accommodation support, digital systems, or post-treatment follow-up. Likewise, the study did not assess whether expected revenues would exceed these costs or whether the same public resources might generate greater benefit if allocated to domestic healthcare priorities, such as reducing waiting times, addressing workforce shortages, or improving access in underserved regions. Future research should therefore include budget-impact, cost-effectiveness, and opportunity-cost analyses.

Fourth, public perceptions of investing public resources in services designed to attract and support international patients were not directly examined. Such investments may be viewed positively if revenues are transparently reinvested in services that benefit the wider population. Conversely, they may be perceived negatively if local patients continue to experience delayed access, staff shortages, or unmet healthcare needs. Because patients and members of the public were not included in the present study, no conclusion can be drawn regarding the likely direction of public opinion. Future research should directly investigate the views of local communities, patients, and frontline professionals regarding the legitimacy and fairness of such investments.

Fifth, the study focused exclusively on public hospitals and did not include private-sector institutions, despite their prominent role in Türkiye’s medical tourism market. Comparative studies could provide a more complete understanding of differences in organizational flexibility, patient coordination, financing, governance, service quality, and equity-related practices between public and private hospitals.

Sixth, the interview guide also devoted unequal attention to the codes subsequently identified in the analysis. It included one question addressing ethical implications and no question explicitly focused on equity, whereas healthcare quality, organizational capacity, and financial implications were examined through multiple prompts. This difference may have limited the depth and frequency of equity-related accounts. Future qualitative studies should therefore include dedicated questions on distributive justice, local patient access, resource allocation, and the perceived fairness of public investment in international patient services.

Finally, the findings suggest that the implications of medical tourism may vary considerably across hospitals and regions. Future studies should therefore avoid treating the public hospital sector as homogeneous. Hospital-specific assessments, longitudinal evaluations, and pilot studies are needed to determine how medical tourism affects local patient access, staff workload, financial sustainability, patient experience, and equity over time. Quantitative models and policy simulations may also help assess the likely effects of quota systems, separate patient pathways, revenue-allocation mechanisms, and regulatory reforms. Cross-country comparisons could further clarify the conditions under which public-sector participation in medical tourism may be feasible, sustainable, and socially acceptable.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

USD

United States Dollar

THCQAI

Turkish Health Care Quality and Accreditation Institute

Author contributions

K.A.: Data collection, study design, mentor. S.D.: Data collection, statictical analysis, writing and critical review of the manuscript. Y.A: Data collection, statistical analysis, writing and critical review of the manuscript. M.A.H.: Mentor, writing and critical review of the manuscript. All authors approved the final version to be published.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Data cannot be shared openly but are available on request from authors: Data cannot be shared openly but are available on request from authors: The data supporting the findings of this qualitative study were generated through semi-structured interviews. Due to the potentially identifiable and sensitive nature of the qualitative interview data, the raw data are not publicly available in order to protect participant confidentiality and privacy. The data are retained by the authors and may be made available from the corresponding author upon reasonable request, subject to ethical and confidentiality considerations.

Declarations

Ethics approval and consent to participate

Before data collection, ethical approval was obtained from Ankara Yıldırım Beyazıt University Social and Human Sciences Ethics Committee (Date: 14/11/2024 and Decision No: 09/515). The study adhered to the ethical principles of the Declaration of Helsinki. Ethical approval was obtained before initiating the research process. Written informed consent was collected from all participants, who were assured of the voluntary nature of their participation and their right to withdraw at any stage. Confidentiality and anonymity were strictly maintained by removing identifiers from transcripts and securely storing all data.

Consent for publication

All participants provided written informed consent for the publication of the data presented in this study.

Ethical considerations

Written permission was obtained from the relevant hospital and ethical approval was obtained from Ankara Yıldırım Beyazıt University Social and Human Sciences Ethics Committee (Date: 14/11/2024 and Decision No: 09/515).

Protection of human and animal subjects

The authors confirm that no experiments were performed on humans or animals for this study.

Data confidentiality

The authors confirm that no identifiable patient data are presented in this article. The study was conducted and reported in accordance with established ethical and methodological standards appropriate to its qualitative design. Relevant aspects of the research process, including participant recruitment, data collection, analysis, and reporting, have been described transparently to ensure methodological rigor and reporting completeness.

Reflexivity statement

The researchers’ backgrounds in health management and hospital settings may have shaped their perspectives and interpretation of participants’ accounts. Throughout the research process, the researchers remained aware of these preconceptions and critically reflected on how their professional experiences might influence data interpretation. Reflexive discussions were conducted among the research team during the analysis process, and alternative interpretations were considered before reaching consensus on the themes and findings.

Competing interests

The authors declare no competing interests.