3. Materials and Methods
Health resorts play an exceptionally important role in overcoming the health crisis caused by the SARS-CoV-2 virus. In Poland, they were a safeguard for the medical infrastructure in case of overcrowding in specialized hospitals. The potential of Polish health spas in terms of spa treatment includes 241 sanatorium facilities and spa hospitals, which hosted 838,500 guests in 2018.
The analysis of changes in the business models of tourism and medical treatment companies operating in spa areas was carried out on the basis of our own research conducted in 2021 by the method of in-depth interviews conducted among managers of these companies acting as experts. The research was conducted one year after the announcement of the SARS-CoV-2 coronavirus outbreak, i.e., after 12 months of operation of spa companies in specific sanitary conditions dictated by business restrictions and lockdowns.
The group of experts consisted of managers from 19 of the largest tourism and medical spa enterprises, with 115 spa facilities. Thus, the managers participating in the study represent 48% of the potential of all sanatorium facilities in Poland [104
The selection of experts was based on the following criteria:
Experts could comment on specific components of the business models. To conduct the research, a research questionnaire was developed and divided into several parts. The first three parts were informative, and only the fourth part was a core set of opinion questions.
The first part of the questionnaire asked experts about changes in their business due to the outbreak of the coronavirus pandemic. Among other things, they were asked which types of spa activities had been reduced and which had expanded.
The next part of the questionnaire dealt with the topic that was the core of the experts’ opinion. It included questions about changes in business models caused by the coronavirus pandemic. The experts were able to indicate those areas of business activity in which they perceived significant differences, in relation to the state before the pandemic. This part of the research was conducted based on the division of business model elements according to the CANVAS concept of A. Osterwalder and Y. Pigneur [10
]. This issue was also extremely difficult due to the fact that the knowledge of business models in spa establishments is fragmentary and most often intuitive, i.e., disordered in relation to any concept of business models [35
]. The research questionnaire contained other thematic issues not related to the business model, so they were included in other publications of the author.
The expert opinion obtained by this method is, at the same time, complementary to the research conducted by the author in 2018–2020 on business models of spa enterprises [36
]. The progress of global changes aimed at implementing the principles of sustainable development in the economy of countries as well as the coronavirus pandemic, which intensified the ongoing changes, forced the need to supplement the ongoing research. The issues addressed in this article complement the existing research on changes in health tourism business models.
4. Results of Own Research in Enterprises of Health Tourism and Treatment
The COVID-19 pandemic has halted or at least reduced the activities of many industries, including the tourism industry. However, a certain part of this industry has changed its business profile to support the emergency response. Tourism and medical treatment enterprises, established for the realization of health and preventive goals during tourist stays in spas through balneological therapy and physical medicine conducted there, undertook various activities during this period. As they are part of the healthcare system, they can play an important role in emergency situations, both when it comes to population evacuation and treatment, or epidemiological activities.
During the first year of the pandemic, from 20 March 2020 to 20 March 2021, Polish health resort companies acted as COVID-19 treatment hospitals, isolation facilities for people in quarantine, post-COVID rehabilitation centers, COVID-19 vaccination points, etc. During periods of reduced incidence, some of them conducted spa treatment, outpatient treatment (spa treatment) and health tourism activities.
The survey of the 19 enterprises in question (covering 115 establishments) in March 2021 established that during the year of the pandemic in the surveyed entities, general spa therapy was carried out slightly more often than in every other enterprise (55.6%) for 177 days per year on average, although this was done in a manner limited by sanitary considerations.
The other activity most frequently indicated by managers was post-COVID therapy, i.e., rehabilitation of post-COVID-19 individuals whose disease left them with ailments that did not require treatment in a specialized hospital. This type of therapy was reported by every other facility (50%). It lasted an average of 153 days per year.
Nearly one in three facilities (27.8%) established isolation rooms for quarantine patients who were confirmed to have the SARS-CoV-2 or COVID-19 virus but did not require hospital treatment. This function was performed by the surveyed facilities for an average of 107 days per year.
In contrast, the role of the COVID-19 vaccination point was performed by almost every second facility (44.4%) for an average of 60 days. However, this result is subject to a significant limitation, as it should be added that vaccination took place throughout the period of availability of the vaccine, as it was not available until January 2021 (Table 4
The longest-running activity during this time was tourist service, which was as high as 270 days. However, this involved very few visitors and occurred in only two establishments. The remaining businesses complied with the restrictions and did not attempt offering tourist service at all.
The function of treating COVID-19 patients was very rarely assigned to spa establishments (11.1%) and usually lasted for about 60 days. The treatment of COVID-19 patients was carried out in infectious diseases hospitals and in specially designated wards of some city and provincial hospitals. During periods of increased incidence, supplementary hospitals were set up to treat people who were ill with COVID-19 but did not require intensive care. These were created in various public places, such as stadiums, market halls, performance halls, and, in a few cases, tourist facilities.
Thus, it should be noted that the change in the dominant profile of tourism and treatment enterprises operating in health resorts consequently led to changes in the components of their business models. The experts, who were also the facility managers, most often indicated changes in the value proposition (83.3%) and in key activities (83.3%), but there were also changes in revenue streams (83.3%) and costs (55.5%), and, in a few cases, in key partners (16.7%).
The biggest changes were seen in the value proposition. It is worth noting, however, that managers did not reduce the customer value proposition, as they maintained their willingness to perform their existing functions during the pandemic, and sometimes performed them to a limited extent. Some reductions occurred in captured values, as the lack of profit opportunities, while considered temporary, was a significant burden for these companies. The greatest changes occurred in the social value proposition, as the implementation of pandemic-control activities was indicated by managers as a value to society.
Among the indicated values for society, the aspect of positive impact on the local economy was the most popular (66.7%). This was about the benefits to the local community provided by the activities carried out by the spa company. This was especially the reduction in the unemployment rate and the increase in income for the community. Undoubtedly, maintaining full-time employment at these facilities was an important aspect—no change in this regard was shown by half of the facilities (52.9%), and another 23.5% limited themselves to not renewing employment with employees whose fixed-term contracts had terminated.
An equally frequently formulated element of the value proposition to society was to serve as a back-up treatment base in national or global security emergencies (66.7%). It is important to mention, however, that the study also found few instances of protests by residents of these municipalities against the implementation of anti-COVID functions due to concerns about the spread of infectious disease to non-tourist neighborhoods.
Other elements of the community value proposition were the effects of implementing renewable energy systems (e.g., solar panels, heat pumps, photovoltaic panels) (22.2%). One site emphasized the role of environmental education of visitors, aiming to reduce water and energy consumption, as well as pollution and waste in the community (5.6%).
Changes were also noted in key activities. The pandemic situation prompted some managers to include post-COVID therapy (61.1%), implementing a vaccination program for COVID-19 (38.8%), or offering space in an isolation facility (16.7%), and providing treatment for COVID-19 patients (16.7%) as key activities.
Due to the lack of income from tourism activities, many facilities experienced changes in revenue and cost streams. A total of 77.8% of the facilities analyzed received non-reimbursable financial support from the state through the Anti-Crisis Shield, and 11.1% of the facilities received special purpose funding to treat COVID-19 patients with ongoing therapies. On the cost side, half of the establishments (55.6%) reported a reduction in costs due to the inability to provide tourism and treatment services. Individual managers also noted non-financial solutions they used. These were deferred payment, and income from production activities carried out together with tourism and medical activities.
Few managers, due to the crisis, supplemented the group of key partners with state administration bodies, including the provincial marshal, with whom they cooperated during that period (16.6%). One manager admitted that the supply chain at his plant was disrupted, not because of reduced demand, but due to the closure or suspension of stakeholder plants.
The obtained research results prove that tourism enterprises can not only have a significant impact on the implementation of tourism activities, but also can play an important rescue role. The example of Polish medical tourism establishments fulfilling additional social roles during epidemic threats reveals that maintaining the link between the tourism business and the public health system is an extremely valuable organizational solution. It should be noted that these businesses are not owned by the state, but are private enterprises and, as such, make their own business decisions. However, their participation in the health system through the implementation of health contracts concluded with the state health insurer imposes on them a number of requirements, including those to be met by healthcare facilities. This fact makes them both a part of the tourism sector and the healthcare sector in which the main contractor is the state insurer (National Health Fund).
In the period of the COVID-19 pandemic, the state’s activities directed at undertaking emergency actions of the national or global range are conducted through the healthcare system. Epidemiological threats are reduced, first of all, by the established hospital departments permanently dealing with infectious diseases, functioning on different levels of health care. Next, actions are taken to increase emergency potential, e.g., by limiting medical activities in other wards to life-saving treatment only, or by enlarging the existing infectious disease units. Further organizational decisions include adapting non-medical infrastructures for temporary medical units with a differentiated role in the chain of emergency or protective actions taken. These may be market halls or office buildings converted into field hospitals, or arrival and departure halls at airports, which in extreme cases may serve as a sanitary buffer in the isolation of quarantined individuals.
It should be noted, however, that the above-mentioned facilities are much more difficult to adapt to healing conditions than hotel facilities with accommodation. Hence, the extremely valuable humanitarian reservoirs are the tourist and therapeutic facilities operating in health resorts. The conducted research proves that these facilities fulfilled their rescue and prevention roles, especially in the field of post-COVID therapy, which was carried out by every second, surveyed company. Another important role performed by almost every third spa facility was that of an isolation facility for people in quarantine. In contrast, the role of vaccine distributor was very popular later on. These three tasks most commonly undertaken by spa facilities enabled them to relieve the burden of medical units, directly saving the lives of COVID-19 patients with complications.
The solution of using such enterprises to counteract the effects of health and especially epidemiological disasters has another important advantage. It should be noted that in accordance with the regulations in force in Poland, sanatorium centers are located in a strictly defined zone of the health resort destination, which is far away from settlements inhabited by the local population. This provides an opportunity to isolate people at risk of illness from large concentrations of residents.
Taking into account the opinion of some researchers who say that such significant events are not insignificant for the future functioning of tourism and, at the same time, give rise to the necessity of implementing pro-developmental changes in tourism [106
], it is worth considering the introduction of additional functions and tasks of tourism and treatment enterprises on a permanent basis. Actions taken by these companies during the period of a pandemic seem to be almost natural in the face of the situation of stopping tourist traffic and the necessity of saving human life and health.
The proposal of adopting applied preventive solutions as key actions of spa enterprises, or at least maintaining readiness for preventive actions, seems to be even more justified in light of the confirmed historical observations [108
] that the frequency of appearance of new viruses and their mutations has increased in the 21st century. Since they will appear more and more frequently, solutions, this time adopted only on an ad hoc basis, may soon become part of everyday life in a few years. However, the adoption of additional functions will significantly affect the structure of the business model. Therefore, it is worth undertaking a discussion on changes in business models in this area. In developing the proposal for the transformation of the business model, the methodology of introducing changes to the proposed literature, discussed in the literature review, was used [26
Undoubtedly, a fundamental component of any business model is the value proposition [78
]. It is the values that give the business meaning. Therefore, it is obvious to include additional prevention and protection activities in the value proposition of the business model. However, supporting the healthcare system in a health disaster involves a complete change in the business profile, and this incurs huge financial costs and dramatically changes the other components of the model. There even seems to be a more complicated process of change in shifting from a tourism to emergency business than occurs in other sectors of the economy.
During the pandemic, many windshield-washer-fluid companies changed their business profile to disinfectant fluid production. Some passenger transportation companies abandoned the continuation of cross-country cruises in favor of cruises bringing tourists into the country. Some universities have refocused their intellectual resources to fight the virus, directing research toward the invention of a vaccine or the development of technology to produce respirators or gates (curtains) to disinfect protective suits, which reduce the risk of infection, when medical teams remove them [109
]. Similarly, the change in the business profile in health facilities required the transformation of almost all elements of the business model; hence, the previously developed models [36
], when the pandemic was announced, proved to be insufficient.
Therefore, it is necessary to propose a transformation of the business model of spa enterprises, taking into account the just-mentioned prevention and rescue activities, such as post-COVID therapy, isolation, and antiviral vaccination. Modifying the previously developed model [36
], the structure of the CANVAS model, which is presented in Section 2.1.2
, special consideration should be given to changes not only in the key activities, taking into account the above functions, but also in the key partners, which should undoubtedly include government entities at various levels and other contractors also undertaking compatible prevention activities. Additionally, key resources should include an adequate level of viral protection materials in the form of viral tests, vaccines, disinfectants, and protective suits, in case an epidemic threat is detected among tourists and a rapid preventive response is needed. Additional items need to be included in the cost structure, as preparedness alone will consume additional costs, not to mention if intensive care is required.
So far, additional items have been listed in the model. It is worth noting, however, that in the case of a tourist stoppage, the elements on the right side of the model lose their significance. It is impossible to build relations with clients in the period of a health threat, to create distribution channels or analyze market segments. As the model is reduced by the above-mentioned components, the revenue structure also changes. The loss of income from servicing tourist traffic has to be covered from other sources. Receiving state subsidies for prevention and rescue tasks should allow the company to at least cover the losses generated during the outage period.
In the case of the value proposition, so far, it has only been noted that it should take into account the additional functions of spa facilities, but it seems that the problem is more complex. Reference should be made here to the breakdown of values present in business models and a holistic view of sustainable values, integrating economic, environmental, and social value forms by S. Evans et al. [78
The identification of value propositions in the business models of tourism and medical enterprises should begin with a discussion of the types of values to be considered. The literature review mentions that one sees both a division of value into customer value and value captured by the enterprise [79
], and a tri-division, emphasizing the importance of social value, which takes into account the values generated by the enterprise toward the local community as well as the environment [93
]. However, the concept of sustainable [78
] value was also cited, which takes into account the value created through the integration of economic, environmental, and social value forms. It is the integration of these three forms of values that makes it possible to define sustainable value in a tourism enterprise (Figure 3
Sustainable value generated by a spa enterprise should take into account the actions and principles that realize the interests of the enterprise’s stakeholders, especially the environment and residents of the tourist destination, i.e., the local community. Nowadays, actions targeting the protection of the natural environment are an obvious requirement in the realization of business plans. There is no need for the company to adapt its own requirements, as they are usually regulated by the state. However, if it happens, it is often an element of competitive advantage of the company, which is trying to raise quality standards [62
On the other hand, the local community, which is also an important stakeholder of tourist activities, may face various problems that seemingly do not find a direct cause in tourism. These include the need for equal employment and promotion opportunities, but also access to natural resources (water, clean air, space) without restrictions generated by tourism.
The literature cites many examples of the negative effects of overtourism, including the consumption of excessive amounts of water or electricity by tourists, as a result of which the inhabitants of the destination feel their shortages. Overtourism is also known to generate excessive noise and garbage, which discourages residents of such neighborhoods, creating antagonism.
The concepts of development of tourist areas long known in the literature [110
] notice the discussed problems, identifying them during the phase of intensive expansion of tourism. At that time, new infrastructure is created, the owners of which are usually no longer local residents, but external investors, often owners of hotels or restaurant chains. The loss of income caused by the decreased interest of tourists in the offer of local farms in favor of new infrastructure causes, with time, the local population to lose the possibility of making a living from tourism; in the best case, it becomes a human resource for new tourist investments (and even that is not guaranteed).
Sustainable values embedded in the business model should initiate the implementation of a management approach that solves the problems generated by tourism. Awareness of their occurrence should create responsibility of the company toward stakeholders, regardless of whether they report problems or not. However, an important element of sustainable value in health tourism enterprises should also be a preventive function in case of disasters caused by health, epidemic, terrorist, and military crises. The enterprise resources accumulated in the implementation of sustainable values should include contingency plans and material resources to reposition the business to provide assistance consistent with the needs of the state healthcare system.
The experience of crises caused by the COVID-19 pandemic will probably force the governments of many countries to create infrastructural, human, material, and financial reserves in case of further health crises. Health tourism enterprises can be part of such reserves, which will probably involve greater integration of these units into the healthcare system and, at the same time, greater state support toward tourism and treatment facilities.
The breakdown of sustainable values in spa enterprises, presented in Figure 3
in the context of their important role during the COVID-19 pandemic, shows the structure of the value generated, offered and captured by the enterprise. However, this is not all, as it is also important to locate the sustainable value component in the model and to identify the relationships with the other components.
proposes a new approach to the business model dedicated to tourism and medical companies, which uses the value triple bottom line and the tenth component of the model, which is activated when the company responds to a crisis situation. The presented transformation of the business model (SusHT-CANVAS+) includes the component of crisis management and critical actions. The additional component is placed between the cost structure and revenue streams components, as this activity will be particularly related to both components; it is directly connected to sustainable value (Sv), which in a crisis situation, becomes a catalyst for change and crisis management, and in a non-crisis situation (i.e., pre-crisis), initiates the company’s readiness to defend itself against the crisis situation. On the one hand, revenues are increased thanks to state subsidies, but on the other hand, maintaining readiness to respond to a crisis situation generates costs or requires the creation of reserves.
It is also important to place the sustainable value in close relation with the other value groups but keep them separate from each other. This emphasizes the importance of this group of values in the whole model, and at the same time, makes it possible to create relationships between the components and the whole set of values or individual values (i.e., with the sustainable value captured by the company and the value offered to customers).
The sustainable value has close relationships with the components gathered on the left side of the model. The relationship with key partners are related to the inclusion in this group of state bodies at local and supra-local levels, which in the case of a crisis, is the first initiator of emergency actions as well as a source of additional revenue related to the funding of these actions. On the other hand, the close relation between the sustainable value and the key actions undertaken by the company are indirect, as these actions are key, precisely after initiating changes related to the change of the activity profile from tourism and treatment to prevention and rescue. An additional relationship is the linking of sustainable value to key resources, the potential of which needs to be augmented with additional material or potential medical staff. This is not about hiring additional medics but initiating connections between enterprise resources and health system resources.
exemplifies such a business model dedicated to health tourism and medical tourism enterprises. The SusHT-CANVAS+ model has the potential to adapt to a crisis situation by excluding the components on its right side, i.e., distribution channels, customer relationships, or customer segments, because, as the experience of the COVID-19 pandemic shows, in such situations, these components lose their importance in the model and sustainable value gains importance.
However, the essence of transforming the business model within the framework of sustainable value should be opening access to such emergency solutions. It is about sharing all knowledge in this area and striving to make this scope of the business model functioning an open innovation, and perhaps even more to make the transformed business model an open business model. Successful examples of such solutions have been discussed previously [79