Cooperation Perspectives in Sustainable Medical Tourism: The Case of Lithuania

Abstract

Sustainable medical tourism is an emergent and growing business worldwide, combining different and very specific purposes from pleasurable travel to sometimes-stressful services of health care. Lithuania can boast of medical technologies and the professionalism of doctors, but this is not enough to compete in the field of sustainable medical tourism. In this situation, cooperation is very significant in sustainable medical tourism. This research investigates a conceptual framework for cooperation possibilities in sustainable medical tourism. Based on a systematic and comparative analysis of scientific literature, the authors of this paper present the conceptual model illustrating the dissemination of sustainable medical tourism through cooperation. The overall results imply that facilitators’ cooperation perspectives in sustainable medical tourism should be highly beneficial for participants and medical tourists. The basis for the improvement of cooperation is communication, contact development, the form of work organization, coordination of work, sharing of knowledge and experience. Cooperation in this particular field determines the role of tourism development, but it is concluded that cooperation in this area is not developed well.

1. Introduction

Medical tourism is an emerging type of tourism. Currently, medical tourism is considered as one of the most developing sectors of the tourism industry in the world. Medical tourism refers to a person travelling to a foreign country with the purpose of receiving medical procedures, with an emphasis on “clinical, surgical, and hospital provision” [1] (p. 58).

This area of tourism in Lithuania also has a great potential for development and growth. The link between medical tourism and sustainability has been demonstrated in a number of national and international scientific publications, where authors thoroughly investigate how this type of tourism can guarantee both economic growth and the stability of new jobs and incomes for countries. As a result of its development, the state would receive a lot of additional revenue to the national budget and attract high-paying tourists [2,3,4,5,6,7]. Lithuania can boast of medical technologies and the professionalism of doctors, but this is not enough to compete in the field of sustainable medical tourism. So far, few tourists arriving in Lithuania, who buy medical services here, have a large share of those arriving—emigrants living in other countries. The development of sustainable medical tourism is relevant for both medical institutions (encouraging their development and growth, especially for private medical institutions) and for doctors (leading to wage growth, as well as professional growth) and for those operating in the tourism sector (additional tourist numbers would result in accommodation, an increase in demand for catering, communication, recreation and other tourist services) and for the whole country (additional tax revenues to the state budget due to increased demand and consumption of individual services, better image of the country).

Tourism as well as medical tourism can be sustainable if developed and managed, considering both visitors/medical tourists and local communities/health care centers. This can be achieved through community engagement, congestion management, reduction of seasonality, careful planning that respects the limits of capacity and the specificities of each destination, and product diversification [8,9,10]. Medical tourism has been gradually gaining popularity in recent years, but this is still not enough to attract as many foreign tourists as possible to receive full-fledged medical services in Lithuania. For optimal results in this area, an important factor is cooperation between health care providers and tourism organizations according to the patient’s wishes. Cooperation can be argued as a joint action of the participants, which is based on mutual agreement, common sense of understanding and a common concept of aspiration. Even at an international and national level (research about the cooperation in Lithuania are not found), there is very limited research on perspectives of cooperation in sustainable medical tourism. This shows that the problem is relevant and to needs to be considered. By solving this problem, it would be possible to more effectively use the possibilities of cooperation in the development of sustainable medical tourism.

We raise two questions, firstly how to increase the dissemination of sustainable medical tourism through cooperation, and secondly what possible solutions are needed for the improvement of the cooperation between facilitators.

The aim of this article is to analyze the perspectives of cooperation in sustainable medical tourism.

The work is organized as follows. In a further section, we present the results and discussion about the analyzed question. We give an analysis of the scientific literature of the concept of medical and sustainable medical tourism; reveal the importance of facilitators in cooperation and present a conceptual model illustrating the dissemination of sustainable medical tourism through cooperation. Section 3 presents research methods and section 4 gives a date analysis of the interview. The final stage of this paper consists of a discussion and general conclusions based on the analysis presented with recommendations for alleviating the problems that were highlighted.

2. Literature Review

The theoretical underpinnings of this study are oriented towards the comprehension of existing relationships between the role of facilitator in the sustainable medical tourism cooperation process and the satisfaction of medical tourists/patients’ needs.

2.1. The Concept of Medical and Sustainable Medical Tourism

Today’s tourism can be considered as a multi-faceted phenomenon developing at particularly fast rates. This growth in tourism services can be based on the increase in demand-supply in both quantitative and qualitative terms. State laws, plans and development strategies often mention the importance of tourism development. However, it is acknowledged that despite this interest in the field of medical tourism, this rather promising area of business, especially its links with culture, to various infrastructure industries, is developing quite chaotically [11,12,13]. In such a situation, it is quite difficult to analyze new types of tourism, with a precise definition of the term itself, unclear detailed areas, activities, unknown forms of communication and methods of disclosure in the general tourism system; it is difficult to elaborate both socio-cultural and economic effects [4]. Medical tourism is an interdisciplinary trend, important in various disciplines, including inter-institutional cooperation. Smith et al. [14] point out that health tourism can be linked to cultural resources, heritage and rituals, as well as to landscapes. According to the authors, it is paradoxical, but the aspirations of various public organizations operating in the tourism sector often remain declarative proposals, and the goals and objectives of the various stakeholders are often implemented individually; there is a lack of cooperation. Long-term tourism strategy has long been emphasized and is necessary for tourism in Lithuania to focus on complexity [11], paying attention to the possible creation of cooperation preconditions with foreign partners.

From an economic standpoint, medical tourism can provide benefits to the government of the destination, residents, and businesses; it can reduce the costs of exchanging information and transporting people [5,15,16]. Medical tourism can also be considered as founding a popular form of culture, whereby people can travel long distances to receive dental, medical and surgical services, while they are generally considered tourists [17]. This type tourism is an emergent and growing business worldwide, combining the very specific purposes of pleasurable travel and potentially stressful services of health care. Most often, patients of medical tourism are willing to travel abroad to seek lower cost, better quality, domestically unavailable, no wait-time destinations for non-emergency medical care [18,19]. Medical tourism can also be defined as a form of tourism that provides medical therapeutic services for patients in collaboration with the tourism industry. This process is usually facilitated by the private medical sector, while it is involved in both private and public sectors of tourism industry [20].

The activities of many people, how they spend their leisure time in recent decades, have fundamentally changed. Different consumer behaviors, styles of individualization, consumption of fun and adventure, advanced globalization and sustainability, increasing luxury and a new health and body awareness are popular phenomena [7,21]. Medical tourism can contribute to the sustainable development if the pillars of sustainable tourism development are highlighted throughout its service chain [21].

The concept of sustainable medical tourism is analyzed as a phenomenon. Therefore, interpretations of this concept are presented differently. Sustainable medical tourism is a type of tourism that has emerged for people traveling to other countries to receive medical, surgical, dental and other services [21]. Medical tourism is a type of tourism where consumers travel to other countries to receive appropriate medical treatment [22]. This type of tourism also can be described as a type of health tourism that combines not only health care but also leisure tourism [23].

Nowadays, tourists have become more focused on quality products and higher requirements for quality and health, and this means that the tourist wants to satisfy his physical, social, spiritual needs through quality sustainable tourism and health care services [24]. Medical tourists, by travelling abroad for plastic surgery and other treatments, enjoy the opportunity of visiting new interesting places at the same time. In this respect, health care is combined with taking vacations [25].

One of the most common reasons for people to travel across the world is for maintaining a good health condition. Regardless of whether he or she is looking for aesthetic plastic surgery in a specialized clinic abroad, complete medical treatments in a distant large city hospital or a relaxing weekend in a nearby spa resort, in all those cases so called medical tourists basically need services of two systems—tourism and health care [6,26,27]. Recently, more and more tourists around the world have chosen medical tourism. This tourism is associated with human health and disease aspects, including quality of life, which is determined by physical, chemical, biological, social, psychological and aesthetic environmental factors having a direct or indirect impact on human health and well-being [28].

Medical tourism often replaces such concepts as health tourism. Connell J. [17] proposed to distinguish the concept of tourism from health and wellness tourism concepts. According to him, medical tourism is the travel of people to foreign countries in order to receive not only medical services but also be a normal holidaymaker. Aluculesei A. [29] and Voigt et al. [30] also emphasize the combination of regular holidays and medical services. Figure 1 describes the differences between the terms.

From Figure 1, it can be seen that medical tourism is a separate branch of health tourism; in other words, the supply of services to consumers traveling to other countries to receive treatment, rehabilitation, dentistry services or surgery. In addition, health tourism involves healthy consumers who care about their health, whose main motive is the preservation and enhancement of health.

Health tourism is a type of tourism where the main purpose is to travel to other countries or within the country in order to increase the holistic, physical, mental and social health potential of health, wellness and other tourism services [31]. According to the authors mentioned above, the following terms are emphasized. Health tourism is a person’s journey to another country with the aim of developing, preserving, restoring or enhancing health through the provision of health and/or health services while taking advantage of other tourism services. Medical tourism is traveling to another country with the primary and main objective to study, rehabilitate or strengthen health by obtaining health services (including medical rehabilitation, medical SPA), dentistry, nursing services, while taking advantage of other tourism services. According to Pocock and Phua [32], health tourism is a growing sector of the tourism industry with policy implications for health systems, especially of destination countries. Health tourism can be described as organized travel outside of the immediate environment in order to strengthen, maintain and restore the physical and spiritual well-being of a person. Medical tourists and medical tourism can be defined as concerted data collection efforts, to be undertaken prior to any meaningful empirical analysis of medical tourism’s impact on health systems.

Many scientists tried to identify motives for choosing medical tourism services abroad. The main motives are highlighted in the research of Gabor and Oltean [31], Fetscherin and Stephano [23], Herrera et al. [21], Černikovaitė and Mameniškis [15], Goodarzi et al. [33], and others. According to the results of the research, the two groups of the motives can be defined. The first group concerns the country (economic situation, political climate, regulatory standards), and the second group concerns the role of the medical provider (costs, accreditation standards, quality of services, professional qualification).

The development of sustainable tourism meets the needs of existing tourists and host regions, while safeguarding and enhancing future opportunities. All resources are expected to be managed in such a way so as to meet economic, social and aesthetic needs while maintaining cultural integrity, essential ecological processes and biodiversity and life support systems [34]. Sustainable tourism practices can only be attained when the holistic principle of sustainability is understood and integrated into the strategic planning of the industry [34,35]. Benefits of the implementation of sustainable medical tourism practices are the reduction/standardization of costs, positive public relations and improved image, satisfaction and rise in demand [35]. In scientific literature [9,23,35,36], it is observed that medical tourism is sustainable only in cases where it makes ideal use of the environmental resources; respects the socio-cultural genuineness of host communities; ensures viable, long-term economic operations, providing socio-economic benefits to all stakeholders; necessitates the informed participation of all related stakeholders, and solid political leadership; maintains a high level of tourist satisfaction. The sustainability of a tourism product mainly depends on the experience of tourists. Aleazurra [37] and Sureka et al. [38] assert that delivering high quality services is the key for a sustainable competitive advantage. Sustainable medical tourism exists when tourism meets the needs of present tourists and host regions while protecting and enhancing opportunities for the future. At the same time, sustainable medical tourism is very important because companies and regions that create significant value have a positive economic impact on the development of the tourism sector and the surrounding area. Moreover, it makes a social impact by giving millions access to improved health care at an affordable price.

Many countries widely recognize the potential for improving the sustainability of the medical tourism industry. According to Graci [39], states attempt to move towards sustainability are hampered by insufficient cooperation between stakeholders to support their sustainability agendas. Cooperation, especially through multilateral partnerships, has been seen as an effective way of supporting tourism development initiatives.

To sum up, it can be said that the concepts of medical tourism and sustainable medical tourism include the aim of people involved in medical services to travel to other countries or other regions to obtain medical services for themselves, not only for medical treatment but also for the prevention of health, while protecting and enhancing opportunities for the future. It is the travel of people inside or outside the country in order to get a complete set of services for mental, mental, physical restoration, improvement and care. It is also important to mention that sustainable medical tourism depends on the experience of tourists.

2.2. The Cooperation of Facilitators in the Sustainble Medical Tourism

For the medical tourism industry to move to sustainability, cooperation is the most important factor. Scientific literature recommends cross-sectoral cooperation as it increases the likelihood of achieving sustainable development results [40].

In the analysis of the articles of various scholars, the concept of cooperation is represented by similar definitions. Cooperation focuses on the general activities of the participants, based on mutual understanding, the pursuit of common goals. Cooperation must first be understood as the free, voluntary, friendly work of all people involved. This is the opposite of exploitation, that is, free cooperation without certain economic or specific personal gain. All the players work together to achieve a common goal and result. The forms of the cooperation are the exchange of recommendations, information, documents, coordination and execution of work. Cooperation is the form used to organize the joint activities of participants, to create a system of cooperation action, to develop cooperative skills actions [38]. Cooperation is also defined as a joint action of the participants in the coordination of joint actions, the establishment of a framework for cooperation actions, organization and development of cooperation relations [41].

In the case of transnational medical tourism and the provision of medical care, cooperation refers to the ‘supply chain’ of care, which includes medical care providers, travel agencies, accommodation, and transportation services providers [42]. Cooperation takes place if both parties are interested in mutually beneficial cooperation. Collaboration may be defined as the joint activity of several organizations, which, in the common good, participate in collective action for the well-being of the joint venture by encouraging the cooperation process or when one or more organizations work together to achieve common goals based on the exchange of information, licensing arrangements, joint ventures or trade associations. These are the reasons why organizations need collaboration—this means that when an individual organization cannot, for some reason, or is reluctant to resolve the difficulties encountered, and it is highly likely that this is due to lack of experience or other factors, this can be avoided. A positive aspect of cooperation is the preservation of the legal independence of both parties [41,42]. If the cooperation does not meet the expected results, depending on the terms of the agreement, participants have the opportunity to withdraw from it. Depending on the forms and intensity, cooperation is related to certain expenses, the time spent by the organizations of employees and, in general, on employment. Therefore, in collaboration, representatives of organizations should evaluate the potential added value, including the risk that potential direct or indirect benefits of cooperation can bring, assessed with a long-term perspective.

The main objectives of cooperation in the field of tourism are:

1. The use of tourist connections to enhance mutual understanding and trust between countries;

2. The use of tourism is mutually beneficial for trade and economic development;

3. Communication and contact development [43].

Medical tourism requires coordinated cooperation between health care providers and tourism organizations according to the patient’s wishes. Medical tourism facilitators can be divided into four main groups:

1. Medical travel planners that can be a tourism company, website, agency or representative persons (e.g., State Department of Tourism) who help a patient in finding medical treatment abroad;

2. Travel agencies or tourism information centers that offer tour plans for health tourists to health or wellness programs;

3. Health providers such as groups of doctors and hospitals that dedicated clinical programs for international patients.

4. Hotels that have expanded their services to connect medical tourists with medical providers or other facilitators [44].

When we discuss the importance and possibilities of cooperation between facilitators, it can be remarked that “many medical tourism facilitators form strategic partnerships, including partnerships with facilitators in other countries, partnerships with insurance companies or domestic employers, and partnerships exclusively with providers accredited by the Joint commission International (JCI) or International Organization for Standardization (ISO)” [36,45].

Hudson [46] suggests medical tourism integration between hotels and health care providers based on a model the “Hotels to Health care” (H2H). The main idea of the H2H model is the possibilities of hotels and hospitals strategically connecting, sharing experiences, and providing quality services to patients, their families, and guests. The author states that the cooperation between hotels and health care providers gives benefits to both parties. In this case, health care institutions are given the opportunity to free up space for other patients and use medical services. Hotels may be exposed to less cyclical demand fluctuations as well, because this can increase the demand for rooms for patients.

According to previously analyzed scientific sources, the basis for cooperation is communication, the form of work organization, coordination of work, sharing of knowledge and experience, and co-workers must provide for the results of joint activities and solutions to problems.

Summarizing the concept of cooperation, it can be argued that this organized joint action of the participants is based on mutual agreement, common sense of understanding and a common concept of aspiration. It is the aim for quality, enhancing mutual understanding and trust between countries. The basis for cooperation is communication, contact development, the form of work organization, coordination of work, sharing of knowledge and experience.

Having performed a systematic analysis of scientific literature, after evaluating and summarizing theoretical insights, the authors of this paper give the answer to the first question and present the conceptual model illustrating the dissemination of sustainable medical tourism through cooperation (see Figure 2). In the authors’ opinion, the development of sustainable medical tourism is influenced by main factors such as globalization, global competition between countries, the variety technologies, different economic and health systems, modern information technologies, policy and legislation. The benefits of SMT development can be assessed through economic, social and environmental issues (e.g., the enhanced quality of human life, health, the country community’s and consumer’s wellbeing, cultural enrichment, reduced costs, improved image of states, raised demand of services and revenue of countries, etc.). It is obvious that this makes a positive contribution to the welfare of the whole society.

The reasons for choosing a different country for sustainable medical tourism can be as follows: better quality of care and services, cost effectiveness, qualification of doctors and staff, less waiting time for procedures, availability to communicate in patient-known languages, medical insurance issues, technological equipment in hospitals, political and cultural stability of destination countries, the opportunity to combine treatment with a tourist program in another country.

On the one hand, the satisfaction of consumers’ wishes is related to the availability of services, procedure options, treatment facilities, tourism opportunities, and travel arrangements; on the other hand, it is related to the dissemination of information about services. According to this, cooperation between medical travel planners, travel agencies, tourism information centers, health providers and hotels play an important role in the meeting of consumers’ wishes. Summarizing, the expansion of cooperation represents benefits for all stakeholders: consumers, health care providers and facilitators. The facilitators of medical tourism can help to save time for the consumers, to provide more information about the services, to offer the most appropriate option, and to get quality care for every detail. In the addition, health care providers and all facilitators can generate more revenue for the business.

3. Methods

As mentioned above, cooperation is one of the most important and effective ways of supporting sustainable medical tourism development, so it is significant to identify the possibilities for cooperation improvement.

In order to analyze the possibilities for the development of Lithuanian sustainable medical tourism from a cooperation point of view/perspective, we will discuss research methods and the organization of the research in the field of medical tourism. We are seeking to answer the second question, what possible solutions are needed for the improvement of cooperation between facilitators?

The purpose of the research is to identify the possibilities of cooperation improvement in Lithuanian sustainable medical tourism.

Research tasks: to find out how the concept of cooperation is understood in sustainable medical tourism; to analyze the practice of cooperation and communication between facilitators in Lithuania; and to identify the possibilities of cooperation improvement in sustainable medical tourism.

A qualitative research method was applied for the study. A purposeful (partially structured) interview was chosen for the purpose of this empirical research. As the interview method is widely used in research of the particular field, we adapted it to determine and to clarify the research problem. The snowballing method was chosen. The size of the sample is not predictable. In our research, we used various sources, such as personal contacts, websites of various institutions in the Republic of Lithuania. A total of 12 different institutions related to medical tourism were contacted. The choice of the interviewers was decided according to the theoretical findings in which medical tourism facilitators were divided into four main groups: (1) medical travel planners; (2) travel agencies and tourism information centers; (3) health providers; (4) hotels. Responsible persons (experts) related to medical tourism from 8 different institutions (2 persons from each group of facilitators) were personally met with.

The interviews took place in the institutions in which the participants of the interview worked. Each interview took around 45–50 minutes to complete, was recorded and then transcribed.

It should be emphasized that during the research implementation, there are well-established strict ethical standards for the implementation of research, which defines the participation of respondents in research. Thus, participation in the research is anonymous and, at the same time, voluntary. All informants are coded and named as informant 1 (I1), informant 2 (I2), informant 3 (I3), informant 4 (I4), informant 5 (I5), informant 6 (I6), informant 7 (I7), informant 8 (I8). The qualitative research was conducted from March to May 2019. The data obtained during the empirical study were analyzed using the content analysis method. The qualitative information compiled through these data sources allowed the researchers to obtain the main findings presented in this paper. The results of the research were separated by themes and sub-themes. Each informant revealed and provided information on the cooperation in the sustainable medical tourism in Lithuania during the research and offered possible solutions of the facilitators for the improvement of the cooperation.

4. Results

An analysis of the data revealed that cooperation between facilitators in sustainable medical tourism is a very important condition for the further development of sustainable medical tourism in Lithuania. At the beginning of the research, it is important to find out what informants know about cooperation in the sustainable medical tourism.

Table 1. Understanding of the cooperation concept in sustainable medical tourism.

Theme	Subtheme	Statements
Knowledge about cooperation in sustainable medical tourism	Joint action and combination of participants	“….is relationship between health providers and tourism agencies according to the patient’s needs. (I5, I8) “…sociable and selfless work of different institutions related with medical tourism services (I1 and I6). “…a joint action of the facilitators and medical tourists, which is based on mutual agreement, common sense of understanding and a common concept of aspiration. (I1 and I6) “…seeking of a common goals and results working together. (I2, I3 and I7) “…it is a promising area for tourism with optimization of mix services to people who require health care or specialized clinical care and other services for family members who are traveling together.” (I7 and I5)
	Communication and sharing of information	“This is the sharing of the information for common goals”. (I1, I5) “…in particular, it is a communication and sharing of the information in joint projects…” (I6)
	Benefits	“...attraction of medical tourists from other countries… (I3) “.. it is increasing the number of medical tourists’ with the purpose of raising the profit of different tourism companies” (I1 and I8) “..it is the preservation of the legal independence of health services providers and medical tourists’ (I2 and I7) “…saving of additional expenses and time “( I1 and I6)

presents the statements of informants, including three sub themes: (1) joint action and combination of participants; (2) communication and sharing of information; (3) benefits of cooperation.

Summarizing the informants’ statements, it can be argued that their understanding of the cooperation concept in sustainable medical tourism is sufficient. The informants point out that cooperation includes aspects such as joint action and combination of participants, also communication and sharing of information, and benefits. The participants are certain that the cooperation relationship and joint actions between different organizations seek common goals and results for the satisfaction of patient’s needs. The participants underline the importance of communication and the sharing of information in the process of the cooperation. Finally, the informants highlight the benefits of cooperation. According to opinion, the participants’ benefits include the attraction of medical tourists, preservation of the legal independence of health services providers, medical tourists, saving of additional expenses and time, as well as raising profits.

In this research, the informants also discussed how organizations participating in this research (such as medical travel planners, health providers, travel agencies, tourism information centers, and hotels) communicate with each other and use cooperation activities in their practice. This category was divided into two sub themes: (1) lack of comprehensive information; (2) lack of common activities between facilitators. See

Table 2. Cooperation and communication practice.

Theme	Subtheme	Statements
Communication and cooperation practice	Lack of comprehensive information	"...no centralized/systematic information in any form." (I4) “…it is difficult to receive and select information between medical tourism facilitators and health providers…” (I7 and I8) "It is necessary to individually navigate and compare." (I3) “Information is enough as the tourism department takes care of it, but this information isn’t systematic …." (I5) “... really little information…, it is necessary to call to the desired medical institutions with a direct interest about the services, prices and other things.” (I2) “...there are outbound tourism agencies specializing in organizing medical tourism in Lithuania.” (I6) "The content of the information is limited enough, a small amount of advertising, offered services and prices …missing the full information." ( I1)
	Lack of common activities between facilitators	“…at times tourism agencies together with health providers organize joint tours to present medical tourism services in Lithuania.” (I5, I8) “Almost every year state tourism department organizes different events, conferences also presentations for tourism agencies, hotels, health providers and also media.” (I2, I4) “…leaflets and other information material is provided by the State Department of Tourism, municipal tourism centers, hotels and medical providers in different languages…but this does not stimulate a cooperation between these institutions…” (I1)
Theme	Subtheme	Statements
Communication and cooperation practice	Lack of comprehensive information	"...no centralized/systematic information in any form." (I4) “…it is difficult to receive and select information between medical tourism facilitators and health providers…” (I7 and I8) "It is necessary to individually navigate and compare." (I3) “Information is enough as the tourism department takes care of it, but this information isn’t systematic …." (I5) “... really little information…, it is necessary to call to the desired medical institutions with a direct interest about the services, prices and other things.” (I2) “...there are outbound tourism agencies specializing in organizing medical tourism in Lithuania.” (I6) "The content of the information is limited enough, a small amount of advertising, offered services and prices …missing the full information." (I1)
	Lack of common activities between facilitators	“…at times tourism agencies together with health providers organize joint tours to present medical tourism services in Lithuania.” (I5, I8) “Almost every year state tourism department organizes different events, conferences also presentations for tourism agencies, hotels, health providers and also media.” (I2, I4) “…leaflets and other information material is provided by the State Department of Tourism, municipal tourism centers, hotels and medical providers in different languages…but this does not stimulate a cooperation between these institutions…” (I1)

.

According to the answers of the informants, it has been noticed that the practice of communication and cooperation is limited and is not sufficiently developed. The informants emphasized two general points: the lack of comprehensive information and common activities between facilitators. The informants stated that there is not enough centralized and systematic information, also that it is difficult to find this type of information, and the content of the information is limited. According to the interviewers’ opinion, activities between facilitators are organized at times or almost every year and not all groups are included in those events. Such a situation does not ensure fluent cooperation between facilitators in sustainable medical tourism.

Finally, in this research, we tried to determine the interviewers’ opinion on how to improve the cooperation between facilitators in the sustainable medical tourism. Results are presented in

Table 3. Possibilities for cooperation improvement in sustainable medical tourism.

Theme	Subtheme	Statements
Improvement of cooperation	Active communication	"…general electronic communication and marketing with medical institutions should be able to provide information through Lithuanian communities abroad or simply disseminate information through the social networks, etc.” (I1 and I5) “...active communication between business representatives, medical institutions, sanatoriums, etc..." (I4 and I8) “…regularly to communicate with consulates and Lithuanian communities abroad providing general information, services, rates and social guarantees …” (I2 and I6) “…constantly communication in electronic space with medical institutions, travel agencies, medical travel planners, etc.” (I3 and I7). “…invest in common websites, their improvement, and convenient information for medical tourists…” (I4 and I8)
	Contact development	"...closely cooperate with the embassies and the Lithuanian communities abroad..." (I2) "...cooperate through the travel consultants, the departments of the State Tourism, and the municipal tourist centers." (I7 and I8) "...cooperate with health forums and medical insurance companies, that it would be possible to reach the individual segments of medical services." (I8 and I5) "… it is also needed by medical travel planners who can find the necessary medical institution, combine price hearings, manage insurance documents, take care of accommodation, meals and study trips." (I4 and I7)
	Sharing of information, knowledge and experience	"It can be useful to create a centralized information portal with news, achievements and good practices, feedback (in Lithuanian, English and Russian)—in order to shape the image of Lithuanian sustainable medical tourism." (I1, I2, I4 and I6) ”…should exist sharing of knowledge between business representatives, health providers, sanatoriums, SPA centers…” (I7 and I8) “ …it could distribute information through all possible channels” (I1 and I5) “The website of the Lithuanian Tourism Department could have specific links to medical institutions.” (I7) “…to share experience about sustainable medical services in close cooperation with the hotels, health institutions, travel agencies, consulates, Lithuanian communities abroad, etc.” (I6 and I3) “…to present innovations during different common events, for example seminars, workshops, conference…. ... while presenting medical services, it is also very important to highlight a specific specialization…” (I7 and I6)

. This category was divided into three sub themes: (1) active communication; (2) contact development; (3) sharing of information, knowledge and experience.

After analyzing the research results, it can be stated that the success of cooperation heavily depends on active communication, contact development and the sharing of information, knowledge and experience. In order to improve cooperation, the informants suggest active and regular communication in the electronic space with various medical institutions, travel agencies, hotels, and medical travel planners as well. They also recommend communication with business representatives, medical institutions and sanatoriums and to create and invest in common websites. Another important point in the opinion of the participants is the development of contacts with embassies and Lithuanian communities abroad, medical insurance companies, travel consultants, departments of State Tourism, and municipal tourist centers. The last recommendations of informants for the improvement of cooperation in sustainable medical tourism are as follows: to create a centralized information portal with news, achievements and good practices, and feedback; to present innovations; to share knowledge and experience about sustainable medical services between facilitators. For this reason, it is necessary to find ways to ensure that the facilitators become more involved and consciously participate in the cooperation process.

5. Discussion and Conclusions

As mentioned in a theoretical part of this article, cooperation is one of the most important elements in the medical tourism industry to move to sustainability. The research above proves that cooperation implies joint value creation through facilitator integration between the service provider and patients. In this process, sustainable medical tourism facilitators present several medical options to patients from introducing medical treatments and service and helping with choosing a country or city for treatment; it is also important to take advantage of a facilitator or an intermediary to advance technologies available in each particular medical destination [44]. Several researchers highlighted the importance of the internet in facilitators’ businesses and suggested that the internet functions as a ‘global marketing platform’, where individuals seeking private health care discover facilitators and hospitals beyond their country of residence [47,48,49]. A large number of patients who are seeking private health care in foreign countries contact facilitators to obtain information on treatment abroad for health care [50]. In the authors’ opinion, important intermediaries or facilitators in this sphere are also foreign tourism information centers, foreign communities and consulates. In this process, the role of medical tourism facilitators include offering ‘case management services’ to medical tourists (patients) related to the medical component of the trip, preparing for hospitalization and the screening of medical history—in many cases, also teleconferences with surgeons—along with services related to travelling arrangements, such as lodge recommendation, airfare tickets, visa application, and tourism packages [20].

The theoretical research findings show that the concept of cooperation involves joint action between the facilitators (medical travel planners, health providers, travel agencies, tourism information centers, and hotels) and a combination of participants in sustainable medical tourism, also communication and the sharing of centralized and systematic information and benefits. It should be remarked that the results of the empirical research fit the theoretical background in this particular field.

As a general purpose of this paper was to analyze the perspectives of cooperation in sustainable medical tourism, we should discuss perspectives in the particular field. After an analysis of various scientific sources on this topic, it can be stated that possibilities of cooperation between facilitators can occur through the strategic partnerships of medical tourism coordinators, including partnerships with organizations from other countries, also with insurance companies and local employers, as well as with partnerships of International Standardization Organization (ISO) accredited providers [45].

Hudson [46] suggests other possibilities and perspectives for cooperation in sustainable medical tourism. According to this scientist’s opinion on cooperation possibilities, it is necessary for medical tourism integration between hotels and health care providers. The author states that the cooperation between hotels and health care providers gives benefits to both parties. In this case, health care institutions are given the opportunity to free up space for other patients and use medical services. Hotels may be exposed to less cyclical demand fluctuations as well because this can increase the demand for rooms for patients.

When we discuss the possibilities of cooperation improvement, in the authors’ opinion, we should consider the most significant and important factors such as communication, contact development, form of work organization, coordination of work, sharing of knowledge and experience. This was proved by the results of the empirical research.

The originality and value of this study consist of identifying the main possibilities of cooperation in sustainable medical tourism in Lithuania based upon empirical research conducted with the aid of an interview. According to the empirical research analysis data, the possibilities of improving cooperation between medical facilitators in Lithuania include the following: active communication between facilitators (in the electronic space, common websites, etc.), contact development (contacts with embassies, Lithuanian communities abroad, departments of state tourism, medical insurance companies) and the sharing of the information, knowledge and experience (creation of a centralized information portal, achievements and good practices, feedback; presentation of innovations in the different common events). It also can be remarked that business representatives, medical institutions, sanatoriums, etc., could distribute information about their services through all possible channels, to create websites related to medical tourism in international languages for patients to access information, because most medical tourists search for their needs using the internet.

Summarizing, it can be stated that the empirical research findings correspond with the statements presented in the theoretical part of this article. Cooperation perspectives in this particular field should, firstly, be highly beneficial for the participants, for medical tourists and for the providers of medical services as well. Secondly, the fact that cooperation possibilities are limited due to lack of centralized and systematic information and uncommon activities between facilitators. Thirdly, the possibilities of cooperation improvement in sustainable medical tourism depends on active communication, contact development and the sharing of information, knowledge and experience.

The presented analysis opens a scientific need to develop a tool for opportunities of cooperation between facilitators in sustainable medical tourism as the research explained the primary role of the facilitators in a sustainable medical tourism and at the same time disclosed the possibilities and provided some perspectives for enhancing cooperation between the mentioned persons. The findings of this study can inform the future researchers on cooperation perspectives in sustainable medical tourism by using them in comparative studies or as a starting point for the development of cooperation as well.

The findings of this study can also suggest guidelines for further research and such research should be performed in the direction of identifying the opinions of the other facilitators (e.g., insurance companies or the International Standardization Organization) and different countries with the purpose of identifying how facilitators can cooperate with each other.

This study also determined various perspectives about some of the issues facing the medical tourism sector.