INTRODUCTION
The development of dental tourism in the Republic of Croatia, and throughout the world, has drastically accelerated within possibilities of advertising on social networks. This was also the case in those Croatian dental clinics that are geographically near or along the state border, which has long led to the arrival of foreign patients, especially those from Italy. Advertising on social networks has helped these clinics to promote their services in the countries from which patients come as well as in countries that are potentially interesting for further business development. Those who recognized this, and were among the first to take advantage of such opportunities, gained a significant advantage over the competition, and in a short time achieved the accelerated development of their clinics. However, few paid enough attention to the risks that arise with a sudden expansion and conquest of a foreign market. Today more than before, and due to the recent pandemic of COVID-19, the risks of such business have come to the fore, although there have been severe indications that in the development of dental tourism when it comes to investment and expansion, special care should be taken.
DISCUSSION
WHAT IS DENTAL TOURISM
Dental tourism is defined by the American Dental Association in 2009 „as the act of travelling to another country for the purpose of obtaining dental treatment“[1]. Dental care is a subset of medical care where tourism has increasingly become prominent[2][3]. It has been one of the popular services sought by tourists, well known in professional circles and well covered in the media[4],[5].
Countries reportedly are known for offering dental tourism services are Hungary, Mexico, Poland, Romania, Bulgaria, Croatia, Argentina, Costa Rica, Peru, Thailand, Malaysia, Singapore, India, Phillippines, Korea[4][5][6][7][8][9][10].
Dental tourism, as a form of medical tourism, is based on providing equal or more valuable dental services outside the home country at more favourable prices with added value in the form of tourist offers and arrangements. Patients go to a foreign country for a cheaper dental service, but also because in the home country certain services are not available to them or are not at the quality level of services of foreign clinics they plan to visit. The decision to go to a foreign country, where the services are more favourable and of better quality also avoids the long wait for certain procedures in the home clinics, that are covered by the basic health care system. In most cases, a more favourable price of services is the main reason, and by including tourist activities in the entire arrangement, there is an increased desire to go to a foreign country, especially if it’s recognized as an attractive tourism destination.
RESEARCH OF DENTAL TOURISM IN THE REPUBLIC OF CROATIA
In the Croatian scientific and professional literature, there is very little representation of research related to dental tourism. The only scientific research conducted in Croatia on dental tourism is „Perception of Croatia as a destination for health tourism in the intermediary market – qualitative research. Final report“ prepared in 2018 by the Institute for Tourism from Zagreb on behalf of the Croatian National Tourist Board[11]. This research focuses primarily on health tourism in Croatia, while only partially relying on dental tourism, although it accounts for the largest share of health tourism in Croatia. This study identified obstacles or constraints to the more substantial development of health tourism in Croatia. The primary problem is poor airline connectivity with key markets, which is analyzed in the example of dental tourism in Hungary, which relies heavily on low-cost air connections with the Unired Kingdom.
Further, two diploma theses, thoroughly deal with the issue of health and dental tourism in Croatia. The article „The future of health tourism in the Republic of Croatia“ explains the problem of difficult development of health tourism in the Republic of Croatia, including dental, due to insufficiently harmonized laws of competent ministries, which should legally regulate the development of health and dental tourism in the Republic of Croatia[12]. „Development of dental tourism in Croatia“ is a paper that defines health tourism and interprets the differences between health, medical and dental tourism, which created an appropriate starting point for understanding the bigger picture and understanding the position and role of dental tourism in Croatia[13].
Here we highlight the first bilingual, English and German guide to dental tourism in Croatia, „Croatia – Dental Tourism 2013/2014. Kroatien – Dental Tourismus 2013/2014“[14], a marketing project which lists all the benefits of using dental tourism services in the Republic of Croatia, with the prices of services and the possible use of various tourist offers (accommodation, cultural, gastronomic) during patients stay in Croatia.
Finally, although it’s not a scientific field, due to their number we mention standard texts available on the Internet that describe dental tourism in Croatia. They have mostly been published on dental clinics’s web sites with attention to get a better position on search results on Google if users search for keywords such as dental tourism, dental implants abroad, dental accommodation abroad, and other keywords related to dental tourism. . An example of one such text is that of the Croatian clinic „Dental Smile Academy“ from Zagreb which wanted to attract English patients[15]. The document provides essential information on prices of services in the Croatian clinic with comparative costs of the same services in the UK, describes the quality of materials used and dental services compared to competing countries, emphasizes superior equipment and technology, describes in detail accommodation, geographical position of the clinic and local gastronomic offer. Although such texts do not deal with analysis with dental tourism from a scientific and professional point of view, they can be perceived as acredible presentation of Croatian clinics that invest in the development of dental tourism and attracting foreign patients.
In the light of the aforementioned, we can find few available research and scientific, i.e. professional and popular papers on dental tourism in the Republic of Croatia, thus this article is one of the few Croatian scientific papers that more comprehensively explains the development of dental tourism in the Republic of Croatia and describes its current situation, advertising services in dental tourism, business risks and procedures and lastly measures that should be taken to avoid risks or at least reduce them with aim of maintaining a successful business.
STATE OF DENTAL TOURISM IN THE REPUBLIC OF CROATIA
Apart from being known as a tourist destination, Croatia has recently become increasingly popular as a destination for dental tourism due to the low prices of dental services. In addition to the sun and the sea, tourists have the opportunity, at extremely affordable prices, to fix their teeth during a visit to Croatia. Dental services such as implantology, prosthetics, oral surgery and orthodontics in Croatia are several times cheaper than in the countries of the European Union, and the level of quality of services is the same or even better.
Although some European Union countries have a much higher standard than others, it is becoming increasingly difficult for people to cover the costs of medical services, especially when it comes to the health of their teeth. Therefore, an increasing number of people in the European Union are considering solving their dental problems outside their country. Lower costs of education and training of staff, opening an office and real estate are just some of the reasons why dental prices are lower in Croatia than in European Union countries. Croatian dentists use the most modern dental equipment in their modernly equipped surgeries and follow the development of science and technology. Therefore, a large number of Croatian dentists have recognized dental tourism as an additional source of income.
When it comes to dental services, implantology, prosthetics and oral surgery are the main reasons why foreigners come to Croatia. In Croatian dental clinics, they receive quality and fast care, individual approach and top service. Patients get a new and more beautiful smile in a short period of time, at affordable prices, while in their countries they would pay a similar service at a much higher price. Also, they have the opportunity to get acquainted with the natural and cultural beauties and gastronomy of Croatia.
In Croatia, dental tourism is a relatively new branch of the economy. Although some clinics have long-term relationships with foreign patients, providing them with dental services for the last 15 years, in recent years, we have witnessed the organized development of dental tourism in Croatia. Clinics from Istria and Kvarner in cities such as Pula, Poreč, Rovinj, Opatija and Rijeka have been doing business with Italian patients for about 30 years. Italians also visit clinics located further south, those in central Dalmatia, especially in Split, which is well connected with Italian ports by waterway. Italian patients as tourists, throughout the year, regularly visit Croatia. Many citizens of the Republic of Slovenia also use services of Croatian dental clinics, those located in northern Croatia, as well as German and Austrian patients who have also been coming to Croatia for decades. A smaller number of Croatian dental clinics are also visited by patients from other European and overseas countries. However, until about 15 years ago, these visits were based mainly on the personal recommendations of acquaintances, friends and relatives. Marketing activities were below today’s level, it was not possible to reach a more significant number of potential foreign patients, and thus not to develop dental tourism more seriously.
Although there are dental clinics throughout Croatia that attract foreign patients, they are most numerous in Zagreb, Rijeka and Split. Interestingly, the development of Zagreb dental clinics in the last ten years has drastically changed the trend of foreign patients going to coastal and Dalmatian clinics. It should be taken into account that the accession of Croatia to the European Union has simplified the movement between the Member States, which has further brought Croatian clinics closer to Western European countries, i.e. patients.
Dental tourism in Croatia is still developing. It currently facing a major global problem and challenge that will determine his future development, which is further discussed in this article.
PRODUCTS AND SERVICES OF CROATIAN DENTAL CLINICS
To bring Croatian clinics closer to economically more robust foreign markets, the critical elements of the offer are those dental services with the most significant difference in prices, which are also the most profitable. These are implantology, oral surgery and prosthetics. Croatian dental clinics also offer other dental services such as, for example, periodontology, endodontics, conservatives and aesthetic procedures, and complete dental services as well. However, a strong emphasis has been placed on implantology primarily because of global price differences. Croatian clinics provide two types of dental implants that often qualify and communicate as „Premium“ and „Low-cost“. However, even the most expensive dental implants in Croatian clinics stand out at a significantly lower price than those in Western European clinics.
A particularly attractive method of therapy „All on 4“, originally conceived by the Swiss manufacturer „Nobel Biocare“[16], was later applied under by other names, by which partial or complete edentulousness is resolved. It is a method in which a fixed denture is mounted on only four dental implants. If a fundamental precondition is met, such as a sufficient volume of the jawbone for implant placement, the patient can reach a final and long-term solution in a concise time. This method is still widely used today, emphasizing the short time of therapy (often in just 24 hours) and the excellent value for money. Prosthetics are most often realized with metal-ceramic and zircon-ceramic dental crowns, in Croatian clinics also significantly lower prices than those in Western European countries.
Foreign patients in Croatian dental clinics are also attracted by diagnostics accompanied by state-of-the-art diagnostic equipment, most often for 2-dimensional and 3-dimensional jaw imaging. This service is, in most cases, free of charge, which is unthinkable in Western European countries.
POTENTIALS OF FOREIGN MARKETS
Dental tourism is based on the provision of equal or more valuable dental services outside the home country at more favourable prices with added value in the form of tourist offers and arrangements. Depending on the country, these differences can become significant. For example, some private clinics in Moldova offer implant or prosthetic services to potential Italian patients far more affordable than Croatian clinics through leased Italian domains and websites as shown in Table 1[17][18].
Despite not being the most favourable compared to other Eastern European countries, Croatian clinics have found ways to enter Western European markets, with still more favourable prices and quality of service. It should be noted that Croatian dentists and clinics in recent years are highly ranked in Europe, when it comes to quality, and are ranked among the best in Central and Eastern Europe[19], a group dental website that includes 27 Croatian clinics that provide dental tourism services, a comparison of dental services in the UK and Croatia shows how many Croatian services are more favourable, even when the costs of travel (arrival/return) and accommodation are included, as shown in Table 2[20].
In Figure 1[21], the statistic presents the cost of dental implants in selected countries in Europe in 2016. Among those listed, the United Kingdom was the most expensive country for dental implants at 3 500 US dollars, compared to 850 US dollars in Croatia.
A study conducted at the University of Medical Technology in Rotterdam shows a comparison of the prices of individual dental services in the UK, Italy, Germany and France[22], as shown in Table 3. The prices in these countries, especially those in the United Kingdom, are significantly higher than those in Croatia. Given the above, a significant breakthrough in the UK market was made by only one Croatian clinic, „Dentum“ from Zagreb, retaining that market to this day.
| Country | Price of service (dental fillings), € | ||
|---|---|---|---|
| UK | 156 | ||
| Italy | 135 | ||
| Germany | 67 | ||
| France | 46 | ||
While the United Kingdom initially seemed a distant and financially unfavourable country for marketing activities, Croatian clinics turned to neighbouring countries, especially Italy. Good neighbourly relations, a long tradition of Italian tourist arrivals and good infrastructural connections seemed to be an ideal starting point for attracting new patients from Italy. Also, advertising in Italy is financially much cheaper than in the United Kingdom.
ADVERTISING OF DENTAL PRODUCTS AND SERVICES IN DENTAL TOURISM IN THE REPUBLIC OF CROATIA ON SOCIAL NETWORKS
Looking back a decade or more, it should be taken into account that advertising on social networks was far more affordable than it is today. With the possibility of targeting, the ads were precisely pointed to the desired group, in contrast to offline, i.e. print media, radio and television, which communicated widely to all groups. Advertising on social networks offers the selection of the target group according to age, gender, geographical position, interests and other factors that much help to achieve the desired advertising results. Facebook and Google were the main channels of communication and advertising platforms, and they have maintained those positions to this day.
If we look at online advertising and the fact that the average CPC (cost-per-click) in 2005 for the whole industry was $ 0,52, and in 2019 $ 3,82, it is clear that advertising 15 years ago was significantly cheaper[23]. This is a direct consequence of the constant growth in the popularity of social networks. Facebook has caused the price of advertising to rise because the number of users who wanted to display ads has drastically increased.
From 100 million Facebook users in the third quarter of 2008, Facebook grew to 2,603 billion users in the first quarter of 2020, as shown in Figure 2, and Facebook is the first social network to exceed one billion users in 2012[24]. Figure 3 shows the number of monthly users of Facebook products from the second quarter of 2018 to the first quarter of 2020[25]
[24].
[25].
The popularity of Facebook is especially pronounced in Italy, where for seven years it has been the leading social network in terms of the number of users, with 80,87 %, which can be seen from Figure 4[26].
[26].
The first Croatian clinics that realized the enormous potential of advertising on social networks in Italy, with an emphasis on Facebook, which provided cheaper and faster results of advertising campaigns than Google, were able to achieve goals unimaginable today. Thanks to the way of advertising, the target group on Facebook got acquainted with the new offer of dental services in Croatia, i.e. outside the home country. It was immediately clear to them that the solution to their problems was not far away and that it was not necessary and expensive but on the contrary. The first contacts were made, and it was not long before new patients arrived from Italy.
Another critical factor that has played one of the essential roles in attracting users to advertiser pages is the advertising rules. Namely, at that time, for the first time, even though from the very beginning of Facebook there were clearly defined Terms of Use, the system was such that it allowed advertising that is impossible to implement today. It is textual and visual content, and a combination of both, which did not necessarily refer to dentistry itself. This, in turn, meant that an attractive Facebook ad could be created that would lead the user to click, but for 'pulling in', despite the assumption that the user, once he saw what it was about, would move on. As in this form of marketing, most of it comes down to the law of large numbers, such advertising has proven to be effective because it has generated a large number of inquiries from potential patients. A step forward occurred when concrete services began to be offered at special prices and when price differences in Italy and Croatia were communicated. However, even in such advertising, there was a delay because not all information related to the offer of services was necessarily communicated, which caused additional curiosity of users and an increased number of inquiries. This primarily refers to the manufacturers of implant prostheses and the technique of doing prosthetic works, which significantly forms the final price. Advertising was allowed to include examples before/after, which usually caused a massive reaction from users because they could identify with the dental case or problem, but also clearly convince of the final result.
In recent years, Facebook has enacted new advertising rules that make today’s advertising significantly more difficult. Among other restrictions, there is a rule that explains that it is forbidden to use before/after examples in advertising: „Personal Health: Ads must not contain „before-and-after“ images or images that contain unexpected or unlikely results. Ad content must not imply or attempt to generate negative self-perception to promote diet, weight loss, or other health-related products“[27]. There are many other rules, and everyone is asking advertisers to apply the advertising strategy for the clinics.
In addition to the above restrictions, it is crucial to pay attention to the text part of the ad. It is not allowed to use words that could mislead the user or create discomfort. Glorification is not permitted, nor is an idealization. Also, Facebook monitors whether the ad is linked to the website and whether the website communicates what the ad represent.
The former practice was, in addition to the main page of the clinic, splitting services into dozens of websites (landing pages), different names and web addresses. They didn’t even necessarily have to communicate the same visual identity of the clinic or make a link to the parent clinic in the name of the web address (URL). Moreover, many of the URLs contained words that referred to the service or region itself, for example: all on 4, implantologia, dental implants, croazia dentisti, dentist zagabria, denti rovigno.
But looking back ten years, the most significant difference in advertising is the user reach for the same invested advertising budget. Namely, Facebook advertising is based on the estimated reach of users conditioned by the spent budget[28][29], as shown in Figure 5 and Figure 6.
For ad campaigns aimed at more than 200 000 people, reach and frequency buying gives advertiser predictable and controlled ad delivery at a locked price. Advertiser chooses how many people see its ads, how often and even the order in which they see them and plan out those details up to six months in advance. The advertiser also knows how far its money goes. Reach and frequency shows advertiser the exact budget it needs to reach and its intended audience. Once advertiser ads have been set up, it will deliver the ads at the booked price[28].
For ease of understanding, imagine that for $ 100, we can reach your ad to approximately 5 000 to 10 000 users. Over time, Facebook began to reduce that reach, so that after a year or two, with the same budget, the reach was reduced to a maximum of 7 000 users, a year later to 5 000, and ultimately todays reach is only 200 to 1000 users. It is not difficult to conclude that this is a multiple price increase that today most smaller clinics can hardly keep up with, especially if it intends to advertise in a foreign market. The results of earlier advertising, compared to today’s advertising, were spectacular and sufficient to launch dental tourism, i.e. for the arrival of international patients in the short term, primarily attracted by cheap and effective advertising.
THE ADDED VALUE OF DENTAL TOURISM IN THE REPUBLIC OF CROATIA
The added value of dental tourism in the Republic of Croatia was offered in the form of a free dental examination without further obligations. This meant that a foreign patient could do a complete diagnostic examination and consultation with specialists utterly free of charge and receive an initial offer for dental services. If we take into account that in most Western European countries diagnostics, examination and preparation of the offer are charged, the fact that it is given as a gift in Croatia is a sufficient reason to decide to go to Croatian clinics.
However, the benefits did not end here. Free transportation in both directions is organized, as well as hotel or apartment accommodation. In the case of Italian patients, the usual practice was to arrange with several patients who, on a specific date and at a specific time, moved in an organized manner from Italy to Croatia utilizing transport by clinics. The variations were either to connect the two cities directly, Italian and Croatian or to stop in passing cities on a given route. In addition to all of the above, patients were offered free accommodation even if they only came for an examination. The arrival of an escort, such as family members or friends, was charged. Those clinics that did not have their means of transport or more strongly developed logistics, hired Italian or Croatian agents whose job was to collect and transport patients with a certain percentage of the commission from the provided dental services.
Thanks to social networks and the investment of clinics in advertising and communication, the word about the quality of services in Croatian clinics spread instantly, which caused even greater interest.
RAPID REVENUE GROWTH OF CROATIAN DENTAL CLINICS AS A RESULT OF INVESTMENT IN ADVERTISING AND COMMUNICATION
If we analyze the data of Fina, the leading Croatian financial agency, from 2017, as an example of a great business year, which speaks of the healthy growth of the ten largest dental clinics in Croatia, we can see a significant increase compared to the previous year, as shown in Table 4[30][31].
Rijeka’s „Rident“ as the largest dental and, in general, the largest private health clinic in Croatia, recorded annual revenue of 16,08 million euros, or 2 % more than the previous year, with a profit of 2,86 million euros.
Zagreb’s „Ars Salutaris“ in 2017 generated revenue of 3,79 million euros, which is an increase of as much as 22,5 % compared to the previous year, with a profit of 270 000 euros.
The growth of the „Implant Center Martinko“ from Zagreb is especially significant. From 2012 to 2016, revenue tripled, from 1,4 million euros to 3,79 million euros, while the profit in 2016 amounted to almost 250 000 euros, or as much as 174,23 % compared to 2015.
Zagreb’s „Identalia“ also joined the most successful Croatian dental clinics, regardless of the decline in revenue compared to 2016, 28,45 million euros, with a profit of 440 000 euros.
A relatively new clinic in dealing with foreign patients, „Arena Clinic“ from Zagreb, in 2017 generated revenue of 3,78 million euros, profitable growth of as much as 51,3 % compared to the previous year and a profit of 120 000 euros.
In the company of the top ten most successful Croatian dental clinics in 2017 were „Orto-Nova“ from Rijeka, „Dental Polyclinic Dr Jelušić“ from Opatija, „Polyclinic Dubravica“ from Šibenik, „Dentvitalis“ from Rijeka and „Digital Smile Academy“ from Zagreb.
Table 4. Business operations of the ten most successful dental clinics in the Republic of Croatia in 2017[30][31].
All these clinics, except for „Digital Smile Academy“ from Zagreb, base their business on Italian patients. Only a small part is occupied by Croatian patients and patients from other countries.
Some clinics, such as „Identalia“ or „Implant Center Martinko“, due to insufficient capacity, have expanded their business through franchises to other dental clinics throughout Croatia. This covered the capacity, but also enabled Italian patients to come to Croatian cities that are closest or more attractive for them to visit.
The rapid growth also required additional investment in the workforce, equipment and infrastructure. The competition of Croatian clinics has led to investment in state-of-the-art diagnostic devices and dental equipment. Many clinics have equipped themselves at the level of world clinics and stood by their side. In 2017, IMTJ, the International Medical Travel Journal, an independent international organization for the promotion of health tourism, named Rijeka’s „Rident“ „The Best International Dental Clinic in 2017“[32].
The number of employees in all sectors of clinics, from surgeries, administration, sales and logistics, also increased largely. Considerable funds have been invested in the development of call centres, often divided into two work shifts because much of the interviewing with foreign patients took place in the afternoon and evening, when patients are available. Significant efforts were made to educate staff in call centres because, in addition to knowledge of a foreign language, they had to undergo communication and sales training.
Basic, commercially available IT systems and solutions were no longer sufficient for such an expanded business, so clinics began to develop their own. In addition to their computer servers and terminals, they developed custom CRM (Customer Relationship Management) and ERP (Enterprise Resource Planning) systems to improve business. Since they are individually developed and adapted to the needs of clinics, it was often a considerable investment.
GROWTH OF PRICES OF SERVICES IN DENTAL TOURISM IN THE REPUBLIC OF CROATIA
These investments came not only from their own revenues and profits but also from various bank loans, especially when it came to the purchase of dental equipment and the purchase of real estate to expand the clinic. Inevitably, there was an increase in service prices because the previous business model proved unsustainable due to significant investments and indebtedness. Free check-ups in clinics remained in several cases, while transport and accommodation began to be charged, and it was free for patients undergoing therapy.
Since advertising on social networks began to be used by other Croatian clinics, there was a 'congestion' in the Italian market. It should be kept in mind that in Italy, in addition to Croatian clinics, Hungarian, Slovenian, Romanian, Albanian, Serbian, Bosnian, Bulgarian, Turkish, Russian, Moldavian and many others were advertised. Croatian clinics could no longer rely only on advertising on social networks, so they looked for other channels of promotion. For example, being one are specialized tourist fairs in Italy, where certain Croatian clinics presented themselves on Italian soil and thus made contact before patients came to Croatia. This way of promotion proved to be financially unsustainable for many and was accepted only by a few clinics in Croatia that is present at several tourist fairs in Italy every year. The additional promotion included paid advertisements in local, Italian newspapers, radio commercials, billboard posters and distribution of promotional materials in shopping malls. The investments were significant, all to better position themselves to attract Italian patients.
THE SENSITIVITY OF THE DENTAL TOURISM MARKET
The sensitivity of the foreign market, i.e. doing business with a foreign market, is also shown by the fact that in 2016 there was a drop in the arrival of Italian patients in the Republic of Croatia after the terrorist attack in March 2016 in Brussels, Belgium. A collective fear of travel was created, not only among the local population but also among the inhabitants of other European cities. Terrorists target public transportation given their direct psychological impact on people’s short-term motivation to travel, thus, paralyzing almost immediately an entire area or even an entire city and consequently causing severe economic damage[33].
The decline in traffic was felt in the transport and tourism industry, as well as in other sectors of the economy, and in the provision of dental services in dental tourism in the Republic of Croatia, which resulted in a drastic decline in demand and interest of Italian patients to come to Croatia. This chaotic situation was relatively short-lived, but it was very indicative and clearly showed what could happen if the influx of Italian patients to Croatian dental clinics were to stop. Even after that shorter period, additional efforts had to be made to patch up the financial gaps created by reduced revenues. This was felt by almost all dental clinics in Croatia that were working with foreign patients from all European countries at the time.
If we return to investments and the consequent rise in service prices, then it should be taken into account that in the meantime the so-called „low-cost“ private dental clinics appeared in Italy, offering more favourable prices than other Italian private dental clinics with prices almost equal to those in Croatia. This was not taken as a potential threat to the business of Croatian dental clinics since even in such low-cost Italian private dental clinics, in addition to the primary service, everything else is charged: diagnostics, examination, counselling, offerings, raw materials, even anaesthesia. . Ultimately, Croatian prices were more favourable, and it was considered that dental work in Croatia was of better quality.
The Italian market, and any other foreign market, could not be observed only through prices, without taking into account the mentality and habits of the people. Italians like to travel, they are not foreign to consumption outside their home country, but the prices of services are essential to them. If they think that, for example, in Hungary, they will get a cheaper and equally high-quality dental service, the extra kilometres will not be a problem for them. And that is exactly what happened. Croatian dental clinics, due to all above mentioned, had to raise prices, and then the interest of Italian patients dropped significantly. In a clinical system that employs 100 or more people, a drop of 20 % or more means 10 to 20 more people in the collective. The decrease in turnover did not stop financial investments and liabilities to banks, so clinics sought salvation in loan rescheduling and cash injections. Now clinics have become patients who need help. Some salvation was seen in foreign and domestic investment funds. Many of them offered to take over the clinics, but at a significantly lower price than the real one. The funds found justification for the low supply in the fact that the clinics are business-oriented to one foreign market, which poses an investment risk.
CONSEQUENCES OF THE COVID-19 PANDEMIC ON THE WORK OF DENTAL CLINICS IN THE REPUBLIC OF CROATIA
And while some clinics were already ready for such an unfavourable takeover, the worst happened, European borders were closed due to the COVID-19 pandemic caused by the new SARS-CoV-2 virus. After China, South Korea and Iran, Italy proved to be the first European outbreak of the disease with devastating consequences and heavy casualties, as shown in Figure 7[34].
All arrivals of Italian patients in Croatia were cancelled, although many appointments were arranged several months in advance. The biggest problem at the time was that no one knew how long the interruption of the arrival of Italian patients would last, or how long the pandemic would last. At that time, it was quite clear that business with foreign nationals would be suspended for at least a few months, which in the case of Croatian dental clinics, whose business is based mainly on Italian patients, met the danger of complete collapse.
[34].
As dental tourism in Croatia also relies on citizens of other European countries, the arrival of patients from Germany, Austria, Slovenia, United Kingdom, France, Belgium, Sweden and overseas countries such as Canada and the United States has been suspended.
Soon followed the recommendation of the Ministry of Health of the Republic of Croatia[35] and other professional organizations, the Croatian Medical Association[36] and the Croatian Society for Oral Surgery[37], to suspend work with Croatian patients and to accept only emergencies. Even emergencies were approached with special caution because there was a possibility of infecting doctors and assistants with the SARS-Cov-2 virus. Although dentists have experience working with patients with HIV or hepatitis, and approach such patients with increased precautions and protection, in an epidemiological situation where the virus is unknown, and there is no cure, the fear and decision to receive and handles only a minimal number of emergencies was justified. Due to the situation, many dental clinics and surgeries have completely stopped working.
In a short period time, the revenues of dental clinics in the Republic of Croatia were reduced to zero, which led to a reduction in the number of employees, i.e. to sending employees on unpaid annual leave. This primarily included employees involved in the logistics part of the business: drivers, administrators, call centre employees, staff to welcome and monitor the movement of patients, maids, janitors and other employees actively involved in dental tourism. Furthermore, business contracts for the rental of hotel and apartment accommodation were terminated, as well as deals with travel agencies and agents in charge of bringing patients from European countries.
At the time of the suspended and drastically reduced revenues, there were still credit obligations to banks that financed the expansion of operations by purchasing new dental equipment, raw materials, movables and real estate. The package of measures adopted by the Government of the Republic of Croatia at the session held on March 17, 2020, which postpone the obligation to pay certain taxes and contributions to dentists involved in dental tourism was not helpful because these measures covered three months with the possibility of extension for another three months and subsequent instalment payment of the debt for 24 months[38]. As it was already probable at that time that there would be no patients from abroad in the Republic of Croatia for at least three months, such measures could not be an aid in the crisis. Only the subsequently adopted decision of the Government of the Republic of Croatia on a new package of measures on co-financing contributions and minimum wages somewhat mitigated the situation and reduced the number of dismissals[39].
STEPS FOR OVERCOMING THE CRISIS OF DENTAL CLINICS IN THE REPUBLIC OF CROATIA
Expansion of business to more countries abroad and more intensive business with Croatian patients
Exit from the crisis must include restructuring the operations of dental clinics, especially in the segment of dental tourism. Even if the COVID-19 pandemic had not happened, clinics needed to turn to a different business model. This primarily involves expanding to more overseas markets resulting in better resilience of dental clinics. Besides, clinics that base their operations on foreign patients incoming must not neglect Croatian patients, regardless of their lower economic power compared to that of patients from Western European countries. It is impossible to successfully develop dental tourism in the long run without focusing on the domestic, Croatian market. However, the trust of Croatian patients has been building for years, and it is impossible to gain it in a short time and out of necessity.
At a time when the borders were closed and when the work of dental clinics with Croatian patients was not yet prevented, some dental clinics decided to drastically reduce the prices of services to attract Croatian patients. Such a business move, i.e. advertising cheap services, met with great dissatisfaction from other clinics and dental practices, so the Croatian Dental Chamber (CDC) reacted with an official statement in which, among other things, it was pointed out the unethicality of advertising and highlighting unethical discounts aimed at had, in addition to competition rules, attracting patients to surgeries or clinics without providing them with complete information on protocols and hidden treatment costs. In case of identified unethical discounts that could not ensure adequate provision of health services in terms of care for patients’ rights and protection and provision of professional protocols and technical conditions as well as appropriate long-term monitoring and prevention of possible complications, the Chamber took measures within its competence to the entities that provided such services, but also to members of the Chamber who knowingly participated in the provision of these services[40].
Drastic price reductions are not only an unethical procedure but also create mistrust in many potential patients. They can rightly ask how the interest in domestic, Croatian patients suddenly arose and why they are offered such discounts, mainly because the services of these clinics were out of reach precisely because of the high prices.
An additional problem is the poorly developed communication strategy of some clinics in crises. In the pandemic, many outpatient clinics also cut off communication with current and future patients. The reason for stopping advertising on foreign markets on social networks and all other platforms in the context of the promotion and offer of dental services or attracting the tourist potential of Croatia is justified. However, in many cases, any communication was interrupted, and all marketing activities were put on hold. This proved to be wrong because those dental clinics that reduced the volume of marketing activities but maintained contact with patients, at the time of easing the measures more easily resumed business.
One section of dental clinics has reduced communication with patients to informative content that communicated advices on what to do if dental problems arise during the epidemic, and the clinics are closed. Here, Facebook has proven to be an excellent platform for online consultations, direct contact of clinic owners to patients, collection of information on dental status, arrival planning and post-epidemic therapies. Such a strategy gave patients the feeling that they were not alone with their problems and that they could count on help. It should be noted that at the time of closing the borders, many foreign patients were in the initial stages of therapy and had made advance payments. It is quite clear that these patients were the first to ask for additional information about the continuation of treatment and how to behave to preserve oral health in the new crisis.
Reducing capacity and focusing on individual services
It is very sure that after the COVID-19 pandemic, the spread of dental clinics will be drastically stopped, especially since the pandemic is still going on. Reducing the capacity of large clinics is already proving to be the right solution. A clinical system of a dozen or more surgeries, a hundred employees and a vast infrastructure will be almost impossible to maintain within a positive financial framework. The trust of foreign patients is seriously undermined by fear and economic uncertainty. It will take a long time for patients to decide to come to Croatian clinics again, which means reduced income. Also, in the process of restructuring, it is inevitable to reduce the number of employees, i.e. to dismiss them.
On the other hand, dental clinics will need to put emphasis on individual services and make an extra effort to show why they are the best in those areas. When it comes to implantology, then clinics must give the maximum to explain to potential patients precisely why implantology is applied and what its benefits are. They need to communicate clearly who is installing the dental implants and with what experience. Showing complete cases through photographs, video and textual descriptions to illustrate how the problem can be successfully solved, will create interest, but more importantly – trust. Clinics need to know that patients primarily want to solve their problem, and it is up to clinics to show how they do it successfully and on what number of patients. A narrower focus on individual services will help the profiling of clinics, and patients to more easily create an image of whether they are in the right place, but also to ultimately accept the price of the service. This will make it easier for clinics as well, because for these reasons they will focus on certain specialists and the purchase of equipment, and the restructuring must include external associates, agencies and companies to reduce business risk. Service prices will continue to be the main reason of interest for foreign patients, but not the only one. Now is the right time for clinics to start developing dental tourism in the full sense and that dental tourism does not only mean transportation, accommodation, services and possible sightseeing during their stay in Croatia but a much broader context.
Dental tourism helps long-term attachment of the patient to the clinic even when he no longer needs dental services. Positive experiences will be transmitted orally, and a recommendation will be created that under normal circumstances cannot be paid for with money. Clinics need to communicate with patients and remind them of their presence continually. Tourist offers must become part of the added value of dental services and must include various arrangements throughout the year and be offered to patients and their families and friends.
Continuation of marketing activities
Although in trouble due to the new situation, dental clinics in Croatia must continue to invest in marketing. Facebook and Google will continue to be the leading platforms for advertising, but following the offer of the service and the target group, all other digital platforms on which advertising is enabled should be taken into account. Clinics must develop their systems for monitoring marketing activities or seek the help of specialized agencies. Today, when the price of advertising on digital platforms is high, and with a tendency to grow, it is vital to know which channels to direct the budget too.
Some larger clinics within their organization have developed their marketing team, which has its pros and cons. It is good that the received information can be processed faster, but it is bad that this information is most often viewed from the perspective of the dental clinic itself and focused on a specific market, without taking into account global trends.
Future marketing activities of Croatian dental clinics must include clearer communication related to individual services and prices. Clinics must be aware that a potential patient, i.e. a user of a digital platform, today no longer feels responsible for having to react to the initial offer after clicking on the ad and asking a question. This is due to oversaturated advertising when clinics offer the same services at comparable prices. The user now knows that he can choose and that he will seek help when he wants to, not when the ad suggests it. Communication skills are essential in the sales segment, and clinics should focus on recruiting and educating sales staff.
Education must be passed on to both current and future patients. For example, pointing out the consequences of delaying the resolution of dental problems or prevention is no longer enough to communicate only through blog posts or Facebook posts. It is crucial to deal with the problem and use all possible communication tools to explain the treatment procedure better, the final result and the benefits of dental tourism. Depending on how well the clinic will be able to assess the need to go beyond standard advertising frameworks and be willing to explore other platforms and connect with other organizations that can help develop dental tourism, so much can expect long-term positive results. Of course, research of other foreign markets must also be included.
CONCLUSION
The current situation caused by the COVID-19 pandemic does not inspire too much optimism. Although the borders with neighbouring countries have opened, clinics are currently working with international patients who come to complete the started therapies. When and if international patients will ever return in the pre-pandemic range, at this moment is impossible to predict. Therefore, the business strategy of clinics in dental tourism must change drastically. Croatia has a huge tourist potential, and clinics must know how to use it. Informing potential patients is crucial. One should be aware of the fact that many Croatian neighbours still do not know which are the larger cities in Croatia and where they are geographically, nor what awaits them when they cross the border and go to an unknown clinic for a dental procedure.
To achieve continuous quality development of dental tourism in the Republic of Croatia, but also in general, it is necessary:
• understand the functioning of dental tourism,
• have realistic expectations related to the realization of set goals,
• develop appropriate branding,
• have adequate logistics, and
• continuously improve, and nurture, communication.
Dental tourism is not just attracting foreign patients and providing services, but it also brings additional values that, in addition to the basic service, complete the offer of dental tourism. Dental tourism represents the long-term achievement of goals, long-lasting connections with patients and relationships that include, in addition to doctors or dentists, many key people inside and outside the organization as well as strategic partners. In this chain, each stakeholder has their responsibility, and umbrella management is essential, and necessary because otherwise the development of dental tourism can be wasted with negative business results.
In the development of dental tourism, it is essential to set goals according to the current capacity of the practice, i.e. the possibilities of appropriate quality treatment of the optimal number of patients on a weekly and monthly basis, and a solid strategic plan, otherwise wrong business moves can occur with poor long-term results.
Developed branding is crucial. Placing a service on a foreign market without an established own brand is a painstaking and challenging journey. What seems at the moment to be recognizable on the Croatian field and which may be enough for regular business is not enough for placement on a foreign market and increase in income. A recognizable brand is created by precise planning, investment and involvement of strategic partners. Accepting the fact that in an international market your brand is a big unknown can help you see the bigger picture and make the right business decisions and moves. Besides, if we start from the fact that branding takes place in the minds of patients and is not tangible, the preconditions are created for the quality development of a quality brand and, in general, dental tourism.
The development of adequate, appropriate, quality logistics is significant. Several elements will prove to be crucial for the development of dental tourism, and the basic ones are marketing activities, educated staff, sales centre and infrastructure available to the organization. The expertise of doctors and assistants, as well as premium services and equipment, are taken for granted. Before targeting a particular foreign market, one should ask who within the organization can follow that market in terms of knowledge of the language, habits, trends, and economic and social circumstances of the target country. Reducing responsibility to some people in the development of dental tourism leads to serial communication and complicated business with a negative effect.
Appropriate, comprehensive (complete), quality communication is of great importance for the quality development of dental tourism. The first contact with the patient begins with the expressed interest of the patient for the services of practice or clinic. Often this interest is lost if sufficient communication is not provided in terms of obtaining all relevant information. Then the excuse for failure is attributed to the inappropriate price, that is, the fact that the competition may offer a more favourable service. However, in reality, the patient is, in fact, not sufficiently familiar with the offer of the dental clinic and is not fully informed of what he gets for his money. Furthermore, communication takes place not only verbally, where the sales centre directly explains the offer by calling, but also through other communication channels such as social networks, newsletters or video channels. It is essential to understand that the fact that, for example, an inquiry came from a website does not mean that the potential patient is fully aware of the service and its value. Communication on several levels and platforms is perhaps the most critical part for the successful development of dental tourism, and it has often been shown in practice that the dental clinic that masters communication skills have a significant advantage over the competition.
When it comes to quality, Croatian dentists and Croatian dental clinics have been highly ranked in Europe in recent years and are ranked among the best in Central and Eastern Europe. This is an additional confirmation that in addition to the tourist potential and the quality of the offer and services, sufficient predispositions have been created for the continued development of dental tourism in the Republic of Croatia, even better and more accessible to a wider circle of patients from around the world.