Vacation for your teeth' - Dental tourists in Hungary from the perspective of Hungarian dentists

Abstract

Background:
Hungary has become a popular destination for foreign patients in the last two decades, particularly in dental care. Since 2008, increasing prices in Western Europe coupled with Hungary's accessibility and availability of dental treatment, has meant the country has become a leader in 'dental tourism'. As the quality of care in Hungary is high and prices are more affordable than in Western Europe, and due to the freedom of movement of people, services and goods within the EU, patient flow into Hungary has increased progressively.

Objectives:
The aim of this article is to provide comprehensive empirical evidence from the perspective of a recipient country in dental tourism.

Methods:
A questionnaire survey was conducted among Hungarian dentists (n = 273). Qualitative in-depth interviews were conducted with representatives of dental professional bodies (n = 10). Both research methods aimed to elicit dentists' views on the presence of dental tourism - particularly the push and pull factors (for example, source countries, competitors, information sources, patient motivation).

Results:
The findings show that there are several reasons why Hungary could maintain a leading position in dental tourism. First, the cost/benefit ratio is outstanding. The affordable price and value for money were already recognised in the early 1990s and were appreciated even before Hungary joined the EU. Secondly, the high quality of Hungary's dental profession: a) dental professionals in Hungary are well-qualified dental practitioners who have received high level dental training; b) dental professional standards are up-to-date and often supervised; c) in Hungary dental technology, the quality of materials and equipment used in dental practices is of European level quality. The rate of complications in dental care is around 5%, similar to other European countries. Finally, previous treatment experiences are positive and patient satisfaction levels are high. More and more patients seek care in Hungary, and more and more patients state that they would be willing to return for further treatment in the future.

Full text

‘Vacation for your teeth’ – dental
tourists in Hungary from the
perspective of Hungarian dentists
E. Kovacs*1 and G. Szocska1
in the district.1 Nevertheless, private provi-
sion is dominant in dental care in Hungary
for domestic and international patients.
Dental tourism often occurs through the
private sector; therefore, the development
of private dental care capacities could be
facilitated by cross-border dental care and
health tourism in general.
CROSS-BORDER DENTAL CARE
Cross-border dental care appeared in
the early 1990s when patients from
neighbouring regions crossed the border
seeking dental care. This brought a sig-
nicant increase in patient turnover in
Western Hungary. The phenomenon was
originally limited to the border regions
with Austria–‘border hopping’ –where
patients pay for private dental
services directly.2-6
Besides Western Hungary, Budapest
became the second most signicant area in
INTRODUCTION
DENTAL CARE IN HUNGARY
Dental care in Hungary is divided into
three service types: 1) primary dental
care, including, among other things, dental
screening, school dental services and den-
tal services for pregnant women; 2) special-
ist dental care; and 3) out-of-hours dental
services. Primary dental care is organised
on a territorial basis. Most dental services
in Hungary are available free of charge
within the single-payer health insurance
system if the patient is entitled for supply
Background Hungary has become a popular destination for foreign patients in the last two decades, particularly in
dental care. Since 2008, increasing prices in Western Europe coupled with Hungary’s accessibility and availability of
dental treatment, has meant the country has become a leader in ‘dental tourism’. As the quality of care in Hungary is
high and prices are more affordable than in Western Europe, and due to the freedom of movement of people, services
and goods within the EU, patient ow into Hungary has increased progressively. Objectives The aim of this article is to
provide comprehensive empirical evidence from the perspective of a recipient country in dental tourism. Methods A
questionnaire survey was conducted among Hungarian dentists (n=273). Qualitative in-depth interviews were conducted
with representatives of dental professional bodies (n=10). Both research methods aimed to elicit dentists’ views on the
presence of dental tourism – particularly the push and pull factors (for example, source countries, competitors, information
sources, patient motivation). Results The ndings show that there are several reasons why Hungary could maintain a
leading position in dental tourism. First, the cost/benet ratio is outstanding. The affordable price and value for money
were already recognised in the early 1990s and were appreciated even before Hungary joined the EU. Secondly, the high
quality of Hungary’s dental profession: a) dental professionals in Hungary are well-qualied dental practitioners who have
received high level dental training; b) dental professional standards are up-to-date and often supervised; c) in Hungary
dental technology, the quality of materials and equipment used in dental practices is of European level quality. The rate of
complications in dental care is around 5%, similar to other European countries. Finally, previous treatment experiences are
positive and patient satisfaction levels are high. More and more patients seek care in Hungary, and more and more patients
state that they would be willing to return for further treatment in the future.
dental tourism;5 around 80% of the dental
ofces in Transdanubia opened branches
in the capital. Budapest became the second
biggest supplier in the area of dental tour-
ism. Due to low cost air travel, Hungary
is now easily accessible from every part
of Europe, not only neighbouring coun-
tries but those further aeld.2,7-10 Hungary
gained its leading position in dental tour-
ism in Europe in 2008.10,11,13 Today, dental
tourism has a 20-year tradition in Hungary
and Hungarian dental care is widely seen
as reliable.12
PREVIOUS RESEARCH
There is a growing body of literature
attempting to reveal the features of health
and medical tourism; however, substan-
tial evidence is still lacking in academic
research. Several studies have aimed to
examine the booming medical tourism
industry from different angles, which
1Health Services Management Training Centre -
Semmelweis University Kútvölgyi út 2, 1125 Budapest,
Hungary
*Correspondence to: Eszter Kovacs
Email: kovacs.eszter@emk.sote.hu
Refereed Paper
Accepted 30 May 2013
DOI: 10.1038 /sj. bdj.2013.995
©British Dental Journal 2013; 215: 415-418
• Scientic research is lacking in the eld
of dental tourism.
• This article examines the core attributes
of dental patient mobility.
• Triangulated data were analysed in order
to shed light on patient motives.
IN BRIEF
GENERAL
BRITISH DENTAL JOURNAL VOLUME 215 NO. 8 OCT 26 2013 415
© 2013 Macmillan Publishers Limited. All rights reserved

GENERAL
contribute to an enhanced understand-
ing of the phenomenon, but evidence is
often vague and sporadic, and contains
estimates.
Articles can be found dealing with
terminology, namely health and medi-
cal tourism and its history. Other studies
concentrate on the economic perspective
providing estimates regarding the volume
of patient mobility, benets for ‘sending’
and ‘recipient’ countries, and the eco-
nomic growth stemming from patient
mobility. Another current approach is
the policy perspective with the intro-
duction of the 24/2011EU Directive on
patients’ rights. Articles looking at patient
motivation usually focus on the proce-
dure-based, the travel-based and the cost-
based components through discussion of
issues such as whether the treatment is
planned, available; affordable/reimburs-
able; easily accessible; quality assured
and accredited with high level technol-
ogy; safe with minimised risks; con-
ducted by well-qualied professionals or
combined with a vacation etc. In terms
of travelling considerations are made
on whether the destination country is:
time consuming to reach; people speak
the required language; politically sta-
ble; taking care of religious diversities;
providing good communication – under-
standable and comprehensive information
etc. Of the information ow, reliability
and continuity are highlighted as crucial
factors. Today valid data are available
from research on patient satisfaction. For
instance – with the focus on Hungarian
dental treatments – patient satisfaction
rates in general show an overwhelmingly
positive picture, with a high level of satis-
faction (above 95%). Research conducted
among German patients14-18 revealed that
the vast majority of patients are highly sat-
ised with the dental service, dentists and
dental treatments provided in Hungary.
METHODS AND PROCEDURE
Qualitative and quantitative analysis were
carried out in order to gain an insight
into the phenomenon of dental tourism
in Hungary (research tools were prepared
and discussed by the ECAB research
team). First, leaders or representatives
of relevant dental professional bodies
were interviewed by a semi-structured
interview on dental tourism and quality
issues. Secondly, a questionnaire survey
was conducted among active dentists
using total population sampling as a type
of purposive sampling technique. The
survey was available online and was also
distributed in collaboration with several
dental professional bodies by post, for
example, it was sent to all recipients of the
Journal of The Hungarian Dentist by the
Dental Section of the Hungarian Medical
Chamber. The nal sample consisted of 273
questionnaires that were analysed.
FINDINGS
MAIN SENDING COUNTRIES
Based on the literature, the ndings of the
questionnaire survey and the conducted
interviews, the main ‘sending’ and ‘recipi-
ent’ countries can be identied. First of all,
it is very important to note that in Hungary
there are two crucial areas where dentists
are treating foreign patients (it is impor-it is impor-
tant to note that these dental ofces treat
Hungarian and foreign patients). Since
dental tourism started as cross-border den-
tal care in Western Hungary, this area is
still remarkable for Austrian and German
patients. This area – due to its proximity to
Austria – specialises in German-speaking
patients. The other remarkable area is the
capital, Budapest, due to the location of
the airport. Patients from Scandinavia, the
UK and Ireland, Switzerland, France and
Italy arrive in Budapest for dental care
(Fig. 1).2,7,11,18
Figure 2 shows the source coun-
tries based on the experiences of active
Hungarian dentists in their own practice,
answering the question: which countries
do your foreign patients come from?
Dentists stated that the main source coun-
tries in their dental practices are Germany,
Austria, the UK and Switzerland (Fig.2).
In terms of Hungary’s competitors,
Poland, the Czech Republic, Slovenia,
Bulgaria, Romania, Turkey and Spain
might be mentioned.10 See Figure3for
estimated rates.
The questionnaire survey showed that a
signicant number of dentists in Hungary
treated foreign patients. Our sample
showed similar rates to other research
regarding the number of dental ofces
treating foreign patients, that is, 20% of
dental ofces.3,10,11
Figure 4 shows that nearly 24% of
respondents treat foreign patients in their
dental practice. In an average month
61.7% of dentists treat mostly Hungarian
patients with health insurance. The rate
of treating mostly Hungarian private
patients is 12.5%. In addition, 77.4% men-
tioned treating foreigners in low volume,
namely 0-10% of their patients per month.
Treating foreign patients in emergency
cases showed a very low level (3.6%).
PATIENT INFORMATION SOURCES
Ninety-five percent of respondents
emphasised that patients arrive via their
own means and only 5% indicated that
they arrive on an organised trip, thus, it
is important to consider where patients
receive information about dental care
abroad. Three considerations must be
underlined here: friends’ recommendations,
the Internet, and medical tourism agen-
cies (Fig.5). Friends’ recommendations or
‘word-of-mouth’ is the most trustworthy
UK
Ireland
France
Scandanavia
Austria
Italy
Other
5%
5%
15%
10%
15% 20%
30%
Fig. 1 ‘Sending’ countries in Europe in 2010
(Source: Attila Kámán7)
010 20 30 40 50 60
7
8.5
11.3
14.1
21.1
21.2
45
49.3
%
France
Ireland
Holland
Italy
Swizerland
United Kingdom
Austria
Germany
Fig. 2 Source countries of the patient turnover in dental practices (%)
416 BRITISH DENTAL JOURNAL VOLUME 215 NO. 8 OCT 26 2013
© 2013 Macmillan Publishers Limited. All rights reserved

GENERAL
source; good experiences generate more
and more satised patients. Patients’ expe-
riences and evaluations can usually be read
on dental practice websites. The Internet
provides widespread information on dental
treatments in Hungary. Medical tourism
agencies also operate and provide useful
information, often in collaboration with
travel agencies. Surprisingly, the majority
of the interviewed dental practices do not
collaborate with medical tourism agencies.
Only 4.4% of the respondents were familiar
with medical tourism agencies, and only
1.8% had a contract with those agencies
(Fig.5).
Another activity from dental ofces that
increases trust is to open an ofce abroad
where patients have the opportunity to
meet the dentists during pre-consultation.
This means that the treatment plan might
be prepared in the home country, before
travelling abroad. Dental ofces abroad
might provide aftercare and liability,
redress as well.
Although pre-consultations ensure trust,
the volume of treatment plans prepared
before the patient travels to the destina-
tion country is 23.3%; therefore, treat-
ment plans after arrival are more common,
76.7%. The language of the treatment plan
is mostly English or in the patient’s mother
tongue (42.1%-42.1% respectively).
Similarly, doctor-patient communication is
mostly in English during treatments (55%)
and 30% in the patient’s mother tongue.
Regarding aftercare, it mostly takes place
in Hungary (72.1%), 5% abroad (mostly
in the UK).
PATIENT MOTIVATION
There are several reasons why patients
decide to have dental treatment abroad.
In England, around 40,000-50,000 patients
seek dental care abroad. In Austria and
Switzerland, the lack of health insurance
could be a signicant patient motivation.
In the Ukraine there is a lack of treatments
available.
Of the main patient motivations, afford-
able prices, good service (good quality,
professionalism, advanced technology)
and the combination of treatment with
a holiday or cultural programmes play a
signicant role.3 Klar also underlines the
importance of the ability to plan.18 For
patients it is remarkable to see in advance
how much time the treatment takes, how
the treatment process is carried out, how
many times they have to see the dentist
and what the aftercare is like.3,20-22
ADVANTAGES AND DISADVAN-
TAGES OF DENTAL TOURISM
Most opinions emphasise the advantages
of dental tourism both for patients and for
the healthcare system; several respond-
ents said there are no disadvantages to
dental tourism.
For patients the following advantages
can be mentioned: they receive good
quality treatment packages from well-
qualied dental professionals for a rea-
sonable price, thus the cost/benet ratio
is excellent. Hungary has provided good
quality treatment for foreigners in the last
20years since cross-border care started.
Patient satisfaction rates are high, and
positive treatment experiences denitely
facilitate the rates of returning for new
treatments.14 Another advantage is the
combination of dental treatment with a
holiday, which is also growing in popu-
larity.3,13,14,18,23,24 Dentists stated that after
reasonable prices (83.5%) and good qual-
ity (35%), combining a treatment with a
holiday (27.4%) and avoiding waiting
lists (27%) count signicantly towards a
patient’s decision to travel abroad. In the
questionnaire survey the following were
highlighted regarding advantages for
patients: 86.2% saving money – around
€1,000, a real patient motivation; saving
time is also crucial, namely, 24% think
time plays a signicant role (36.7% value
a saving of oneweek, 33.3% one month);
patients are also motivated by easy acces-
sibility of treatments (19.3%) and special
treatments (17.7%).
In summary, saving time and money,
quick and easy access to good quality
dental care increase the rates of patients
travelling abroad for dental treatment.
For the healthcare system dental tour-
ism might bring development, hi-tech
equipment, and may trigger continuous
technological developments. Dental tech-
nology can be improved via increasing
patient ow (22%) and income (68.2%).
Forty percent of respondents stated that
they had more advanced, higher qual-
ity equipment due to increased income.
Further, dental ofces create new jobs
(13.7%), prevent Hungarian dentists from
leaving the country, and might reverse
‘brain-drain’ (9.7%). Dental tourism – via
technological development – also has a
good impact on continuous dental educa-
tion, as skills and knowledge need to be
up-to-date. Moreover, dental tourism also
facilitates growth in other sectors of the
tourist industry, which triggers economic
growth (12.8%).10,21
As far as disadvantages are concerned,
only the patient’s perspective was empha-
sised, namely time pressure. Receiving
aftercare in case of complications or lack
of aftercare were mentioned; however,
Fig. 3 Recipient countries in Europe in 2007
(Source: Tolnai et al.19)
Hungary
Poland
Spain
Bulgaria
Turkey
15%
7%
7%
32%
39%
0
10
20
30
40
50
60
70
80
%
23.8
76.2
Yes
No
Do you treat foreign patients? (N=273)
Fig. 4 Rate of treating foreign patients (%)
010 20 30 40 50 60 70 80
10.2
42
73.9
Medical tourism agencies
Internet
Friends’ recommendation
Fig. 5 Patients’ information sources (%)
BRITISH DENTAL JOURNAL VOLUME 215 NO. 8 OCT 26 2013 417
© 2013 Macmillan Publishers Limited. All rights reserved

GENERAL
most of the time patients are aware of
the whole dental treatment process in
advance, and unexpected complication is
rare, around 5%, similar to other European
countries. In the survey 72.1% of the den-
tists stated that they provide aftercare for
foreign patients. Time pressure leads us to
overtreatment and aftercare issues, thus,
more and more dental ofces open dental
ofces abroad where pre-consultation and
aftercare can be provided without return-
ing to Hungary. This also supports liability
and redress issues.
CONCLUSION
This article aimed to provide comprehensive
empirical evidence from the perspective of
a ‘recipient’ country in dental tourism. The
ndings show that several reasons can be
listed for Hungary gaining the leading
position as a destination country in dental
tourism. First, the cost/benet ratio is out-
standing. The affordable price and value
for money has been appreciated for the
last three decades. Secondly, the high qual-
ity of the dental profession is highlighted:
dental professionals are well-qualied, and
Hungary has a long tradition in dental train-
ing and practice. Further, dental professional
standards are up-to-date and European level
dental technology is used. Finally, previous
treatment experiences are positive and patient
satisfaction levels are high. More and more
patients seek care in Hungary, and more and
more patients state that they are willing to
return for another treatment in the future.
The volume of patients arriving in Hungary
shows an increasing tendency towards rec-
ommendation facilitated by word-of-mouth.
Based on the ndings of this research
project, it would seem that the phenom-
enon of patient mobility within European
member states is benecial for all affected
parties and in particular for a positive
patient experience.
We thank all questionnaire respondents who took
time to provide us with the requested information.
We particularly wish to thank all the institu-
tions participating in the study: Dental Section
of the Hungarian Medical Chamber; Hungarian
Dental Association; National Advisory Board of
Healthcare – Dental and Oral Disease Department
and Council (previously Professional Advisory body
of Dental and Oral Disease); National Institute of
Oral and Maxillofacial Diseases; National Dental
Public Health Authority – Chief Dental Ofcer;
National Committee for Hungarian Dentistry. Other
dental bodies interviewed: the Association of Leading
Hungarian Dental Clinics and the Hungarian Dental
Tourism Company.
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