Introduction: the development of health tourism in challenging times – a focus on the Visegrád countries

The Visegrád Four (V4) countries – Czechia, Hungary, Poland and Slovakia boast a rich history and heritage of health tourism culture. These countries have traditionally been attractive destinations for medical tourism due to their high-quality healthcare services, coupled with relatively lower costs compared to Western Europe. In addition, this region is famous for spas because of the long history of balneotherapy, as well as the increasing popularity of wellness products (Dryglas and Smith, 2023).

However, the development and management of spas was negatively affected by the unprecedented COVID-19 pandemic. The pandemic gave rise to many uncertainties and new risks to economies around the world, and the Czech, Hungarian, Polish and Slovak health tourism sector and destinations were no exception (Kinkorová, 2023; Šenková et al., 2021; Szromek, 2021a,b). In order to recover quickly after the pandemic, there was a need for agile management of health tourism enterprises and destinations that could harness the efforts of different stakeholders (Wan et al., 2022): consumers, local community, businesses and destinations. This was not an easy task as the world experienced multiple paradoxes at a time which will remain in history as a period of uncertainty, unprecedented global socio-economic and political challenges. On the other hand, it was also a time of transformation, innovation and new opportunities arising from the fourth industrial revolution (Dorcic et al., 2019; Sigala, 2020).

The crisis and its concomitant challenges forced the re-development of a sector that was already partially in danger of becoming obsolete. According to the European Spas Association (ESPA, 2020), the post-pandemic era presented a unique opportunity for revitalisation and acknowledgement of the significance of health tourism enterprises and destinations. In post-COVID-19 times, individuals prioritized disease prevention and increasingly utilized spa enterprises for this purpose (ESPA, 2020). According to several researchers, health tourism emerged as a prominent sector after the pandemic (Dryglas and Smith, 2023; Ma et al., 2021), therefore medical and wellness spas and destinations were required to re-consider their approach (Smith, 2021). In addition to mitigating the severe effects of the Coronavirus and helping to regenerate the general health of the population, health tourism development provided an opportunity to promote those enterprises and destinations that were in decline or were not sufficiently valued (Puczkó and Stackpole, 2021).

The post-pandemic economic, technological, social and environmental challenges could be seen as an opportunity for managers to rethink old strategies and implement improvements. This helped health tourism enterprises and destinations not only to recover, but also to transform and develop in a much more sustainable way (Dryglas and Salamaga, 2023). In light of the difficult socio-economic situation for health tourism enterprises and destinations, marketing and management measures needed to be undertaken to adapt their economic, social/human and environmental resources policy to the changes in the health tourism market (Lubowiecki-Vikuk et al., 2023; Pinos Navarrete and Shaw, 2021). In Poland and other European countries, including in particular V4 countries like Czechia and Slovakia (Derco, 2020; Kraftová et al., 2020), it was recognised that economic as well as social and environmental problems partly needed to be solved by managers of health tourism businesses and destinations.

Recent research on health tourism enterprises and destinations clearly justifies the need to explore the subject of the challenges and opportunities for the development of health tourism in the four Visegrád countries. This includes short- and long-term strategic approaches that need to be taken by health tourism supply entities and managers of health tourism destinations to build resilience capacity (Dryglas and Salamaga, 2023), ecosystem services (Lubowiecki-Vikuk et al., 2023), sustainability (Szromek et al., 2023) health tourism experience (Dryglas and Smith, 2023) and competitiveness on the European health tourism market. By recognising knowledge and research gaps, this thematic issue aims to contribute to the understanding of health tourism enterprise development and destination management in the post-pandemic context. This includes guiding the development of theory and practice, while making positive recommendations for navigating challenges and building resilience.

Studying the concept of health tourism in a post-COVID-19 era can provide valuable insights for policymakers, healthcare providers and tourism businesses in the Visegrád countries. By understanding the challenges and opportunities in this sector, they can develop effective strategies to attract health tourists and to ensure the sustainable growth and development of enterprises and destinations. Additionally, examining the factors influencing the decision-making process of health tourists can help tailor marketing campaigns and improve the overall health tourism experience.

This issue analyses the development and management of health tourism in the Visegrád countries. For this purpose, the construct of health tourism developed by Smith and Puczkó (2009, 2014) was adopted, which includes two main forms: medical tourism and wellness tourism. Although medical tourism often refers to surgical interventions, it can also include balneological treatments that are administered in a medical spa. Wellness tourism, on the other hand, tends to take place in spas that are designed for relaxation and leisure.

The thematic issue focuses on an area of Europe that has been relatively under-researched, namely the Visegrád countries. Article contributions range from literature reviews and conceptual papers to research that is based on primary data and practitioner input, resulting in both theoretical and practical recommendations and solutions to challenging issues. The invited authors are experts in the fields of medical balneological spas, as well as in wellness tourism management. This ensures that the problem of health tourism management in the face of challenging times is discussed from various perspectives.

The first article in this thematic issue is a conceptual paper (Białk-Wolf et al., 2025), which identifies the factors that help to create a health region in the context of sustainable development. Indicators are identified, which can be used to characterise a health region, including environmental, social and economic spheres from both a supply and demand perspective. It is important to consider how regions and destinations are developed, especially for the V4 region, where the countries and destinations share similar backgrounds and challenges. The authors provide a set of crucial indicators within these spheres that could be used to develop a health region, including (unspoiled) natural landscape, economic vitality, improved quality of life for local communities and health promotion for citizens and tourists alike. The need for health-orientated policy formation, regulation and collaboration among stakeholders is emphasised, along with strategic planning for sustainable development.

The second article (Stelmach et al., 2025) is also conceptual and identifies and explains the importance of Business Intelligence and Analytics (BI&A) in health destination development. Although BI&A systems can help to provide information for making knowledge-based decisions about the directions of development of health destinations, they are rarely used and research remains scarce. BI&A can be useful for creating business models, forecasting new business scenarios, understanding threats and building resilience (important in times of crisis like a pandemic, for example) and adapting and catering for changes in consumer behaviour. Such information systems can help to connect health tourism destinations and health tourists in a way that tailors offers to their needs, for example by providing information about programs and treatments and using guest satisfaction measurements or sentiment analysis. The authors present case studies and examples which demonstrate current and good practice, which could be applied to V4 health destinations.

The third article (Smith, 2025) provides a case study of health tourism in Hungary based on both primary and secondary data. The data was derived from a wider study (a Delphi Study) that examined the situation of health tourism development in the V4 region during the COVID period (2020–2021). Although much of the article focuses on Hungary, it is noted that there is some collaboration between the countries (e.g. employee holiday exchanges between Hungarian and Czech thermal spa destinations). The region-wide data also revealed common challenges for the four countries, such as decreasing national funding for balneology treatments for the domestic market, the struggle to meet quality standards for paying and international guests, the need to improve infrastructure, low employee salaries and recruitment difficulties. Differences were also highlighted, for example, greater concerns in Czechia about the tension between balneology treatments and the leisure and recreation function of spas. In Slovakia, the differentiation between spas offering medical treatment and those centred on leisure or wellness services tends to be clearer than in Czechia or Hungary. The latter attract more foreign tourists and result in shorter stays. Poland seems to have embraced the shift towards leisure, recreation and wellness more than the other countries, but further investment in facilities would be needed to cater more fully for changing customer needs. In Hungary, it seems that facilities offering medical treatments and services are slowly decreasing while spas offering wellness and beauty treatments are increasing. Nevertheless, recent statistics suggest that guests’ numbers have not yet reached their pre-COVID levels. Hungary ideally needs to address staff shortages, especially in the countryside, as well as engaging in product development and quality enhancement to attract and retain foreign and paying guests.

The following two articles (Košíková et al., 2025; Derco and Tometzová, 2025) address the important issue of customer satisfaction in the Slovakian context. The first article analyses customers’ perception of the quality and range of services provided by spa companies in Slovakia based on a questionnaire undertaken in 2020. The data compared the situation of self-payers compared to those who were reimbursed by health insurance companies. The authors note that several crises (pandemic, war, inflation) had led to a decrease in visitors from abroad, as well as a reduction of local guests who could self-fund. Questions arose (as they did elsewhere in the V4 region) about whether the Slovak spa industry is sufficiently supported by the state and health insurance companies, and whether the demand for high quality services from foreign clientele can be met. The authors highlight the significance of Importance-Performance analysis (IPA), which can help to measure satisfaction with the quality of an organization’s product or service compared to the customer’s expectations. The data revealed that although customers were actually quite satisfied with the quality of their experiences, spas need to think holistically, as satisfaction with one area of experience (e.g. a treatment) cannot necessarily compensate for areas of dissatisfaction (e.g. catering services).

The second article (Derco and Tometzová, 2025) analyses customer satisfaction across 20 Slovakian spa locations using Performed Sentiment analysis of more than 5000 Google reviews. As in the previous study, the majority of the results were positive, but the rated attributes differed depending on the type of accommodation. The relatively few negative reviews highlighted insufficient infrastructure (a common challenge in the V4 region) relating to lack of investment, neglected buildings and the need for renovation. Some criticisms were also made about the rude or unpleasant behaviour of the staff, the poor quality or unhealthy food (similar to the previous article) and the lack of value for money compared to the high prices paid. Very few negative comments were made about actual treatments. Unfortunately, the major cause of dissatisfaction related to the outdated appearance of the spas and lack of maintenance, which is difficult to address without increased funding. Salaries in the V4 region tend to be somewhat low and there are staff shortages in many locations (especially in the countryside), so attracting, motivating and retaining good employees can be challenging.

The second half of the thematic issue features articles that focus on the Polish context. The first article by Mirek (2025) draws on six interviews with Polish spa enterprises to examine how managers perceived the operation of spa enterprises during the COVID period and the two years that followed the pandemic. Many of the identified issues were relevant also to other countries in the V4 region. This included increased government regulations and hygiene protocols, the need for additional funds and financial support, health-related or psychological challenges relating to staff, issues around vaccinations and quarantine, guest cancellations and a drastic decrease in numbers. Interviewees felt that spas enterprises could have been used more for COVID survivor rehabilitation or for dealing with long-COVID and related complications. The post-COVID period included the challenges of the proximity of the war in Ukraine and rampant inflation. Current issues that need to be addressed relate to staff shortages (including balneology and physical medicine specialists), and catering more to the needs and expectations of guests, including more flexible treatment schedules and making spas more attractive to younger consumers. The choice of spa is often determined by the quality of the hotel facilities or tourist attractions, rather than the medical services, which could result in the marginalization of the role of medical services in spa treatment. The relationship between spa enterprises, government authorities and local communities will also determine their future success.

The second article (Lubowiecki-Vikuk and Białk-Wolf, 2025) presents a scoping review, which maps knowledge of and outlines directions for medical tourism in Poland. Medical tourism is defined very comprehensively, and the authors emphasise the fact that rehabilitation services in spas require specialist training. This is one of the defining characteristics of balneology spas in the V4 region, where doctors and specialists are required to run the medical services. The authors note that tourists from Western Europe are now using more medical services in Central and Eastern Europe than they did in the past, and that Poland is the most frequently chosen country. The authors’ bibliographic analysis of literature relating to Polish medical tourism concludes that there is a need for more research on the holistic nature of the medical tourist’s experience, the role of brand image and trust, as well as examining the full scope of “value perception” of domestic, foreign and diasporic medical tourists.

The third article about Poland (Białk-Wolf, 2025) analyses the factors that attract foreign tourists to Poland as a medical tourism destination, including affordable prices coupled with a relatively high quality of services. A survey of medical facilities was conducted in 2022, along with analysis of recent statistics and interviews with 13 experts in medical clinics dealing with foreign patients. Dental, spa and aesthetics treatments are the most popular, but dental clinics had noted a significant decrease since COVID, and demand for medical tourism decreased further because of the Ukraine war. Nevertheless, medical tourist numbers are increasing from many countries, including Arab markets. It is also important to mention that many Polish patients are dissatisfied with the insufficient public healthcare system and are more frequently turning to private healthcare, which can result in some clinics withdrawing from the international market. The changing nature of the competition was noted, with Turkey becoming a bigger competitor than Hungary or Croatia, partly because of escalating labour costs and decreasing price competitiveness. Overall, it was suggested that promotion and branding could be improved, along with increasing the supply of health services catering for foreign tourists.

The final article by Mathijsen (2025) explores how the diaspora population might be instrumental in rebuilding medical tourism for countries with migration-intense populations. Diasporic medical tourism comprises a segment of ‘invisible customers' who were early adopters of medical tourism in specific nations. Despite economic and social disruptions, they constitute a significant proportion of travellers who visit Friends and Relatives (VFR category) and often follow a “home-is-safer-than-abroad” bias. Thus, they present a sizable market of potential consumers, particularly during periods of instability. The author explores how far diasporic medical tourism could be instrumental in re-building the industry in Poland in the post-COVID period. Despite the fragmented and insufficient data to draw definite conclusions, it seems that Polish diasporic tourists are quite committed travellers who are content to return home for treatments.

This theme issue focuses on the development of health tourism in the Visegrád countries during challenging times. This includes not only the COVID pandemic, but also the war in Ukraine and rising inflation levels. Political instability and health risks clearly act as barriers to travel, but economic crises also affect spending power of consumers and government funding. Many health destinations and facilities in the V4 region have not yet returned to their pre-COVID levels. It can be seen that spas and health resorts are suffering from under-investment for infrastructural development and renovation, as well as staff shortages. This can result in a lack of customer satisfaction in a number of key areas, many of which are essential when creating a holistic health experience. Government funding for domestic health tourism trips is decreasing meaning that guests will increasingly be forced to pay for their own spa visits and treatments. Insufficient healthcare systems in the V4 countries may also force citizens to pay for private healthcare, leading to a lack of services available for international medical tourists. This means that other countries outside the region (e.g. Turkey) can fill the gap and offer more competitive prices too.

The authors suggest that there is a need to think more holistically about health tourism regions as well as individual destinations. This requires a strategic and sustainable approach, which takes into consideration numerous indicators from the economic, environmental and social spheres and considers the needs of all stakeholders. From a business perspective, it would also be important to develop better information and data management systems, for example BI&A, which helps to identify programs and treatments, and to tailor offers to the right segments of consumers, or Importance-Performance analysis (IPA), which can help to measure satisfaction with the quality of an organization’s product or service compared to the customer’s expectations. To achieve such aims, innovative product development and an upgrading of infrastructural and service quality would be needed. The shift from balneology to wellness requires careful consideration, as currently, facilities are separated in some cases (e.g. in Slovakia), but uncomfortably combined in others (e.g. in Czechia or Hungary). It is necessary to recognise the very different needs and expectations of those guests who are funded by health insurance companies for medical treatments, and those who are seeking short-term leisure and relaxation. It is also important to consider the needs of younger guests, who may not yet need medical treatments, but who may become future guests if they are attracted to spas from a young age.

Overall, this thematic issue highlights the opportunities and challenges facing the development of health tourism in the Visegrád countries and offers insights for researchers, policymakers, healthcare practitioners and other stakeholders in the industry. Effectively managing the development of health tourism in the Visegrád countries requires a holistic approach that prioritizes customer satisfaction, promotion and collaboration. By addressing these key areas, the Visegrád countries can capitalize on the growing trend of health tourism and position themselves as competitive actors in the global market.

This research was financially supported by AGH University of Krakow grant No. 16/16.200.396 B510.