# Health Tourism in Brazil: The City of Teresina Case

Átila De Lira, Herbert Gonçalves Espuny, Pedro De Oliveira Costa Neto, Reinaldo De Araujo Lopes, Josimar De Oliveira

► To cite this version:

Átila De Lira, Herbert Gonçalves Espuny, Pedro De Oliveira Costa Neto, Reinaldo De Araujo Lopes, Josimar De Oliveira. Health Tourism in Brazil: The City of Teresina Case. IFIP International Conference on Advances in Production Management Systems (APMS), Sep 2014, Ajaccio, France. pp.579-586, 10.1007/978-3-662-44736-9_70. hal-01387936

HAL Id: hal-01387936

https://inria.hal.science/hal-01387936

Submitted on 26 Oct 2016

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
HEALTH TOURISM IN BRAZIL: THE CITY OF
TERESINA CASE

¹Átila Melo de Lira, ¹Herbert Gonçalves Espuny, ¹Pedro Luiz de Oliveira Costa Neto, ¹Reinaldo de Araujo Lopes, Josimar Alcantara de Oliveira

¹Paulista University – UNIP, Graduate Program in Production Engineering,
Dr. Bacelar St. 1212, São Paulo – SP, Brazil

{atilalira@hotmail.com, hgespuny@uol.com.br, politeleia@uol.com.br, mestradoua@bol.com.br}

**Abstract:** In recent years, the global growth of the economy contributed to the significant increase of tourism in the world, where the movement of foreign exchange earnings doubled in the last ten years, spreading its effects in Brazil, and particularly, growth in the Northeast region, globalization and other short term changes. This work aims to presents how a Brazilian state, among those with lower income per capita in the Federation, such as Piauí, has a health care system in its capital which is a benchmark in Northeastern Brazil, influencing positively health tourism in this regims. The research deals with issues involving tourism as a product and service, having as a result a cluster of health enterprises in the city of Teresina, whose economic expression justifies its importance as a generator of income, employment, science and technology and a promoter of sustainable development in that city.

**KEYWORDS:** tourism, public health, sustainable development.

# 1 Introduction

The State of Piaui in northeastern Brazil, that until recently was considered one of the most backward in the country, has currently been highlighted by actions that project positively it on the national scenario. One of these actions was cited in an article approved at the congress of APMS 2013 [1].

According to the World Tourism Organization [2], the global tourism lifted foreign exchange revenues at approximately U.S. $ 919 billion in 2010. There was a slowdown in this tourism sector in the light of the global economic crisis of 2008, which caused a certain instability of trust for future events. However, despite the crisis, a comparative analysis of the ten years prior to 2010 shows that the foreign exchange earnings with tourism in 2008 (U.S. $ 857.40 billion) was 92.67% higher than in 1999 ($ 445, 00 billion), demonstrating a significant growth. Still according to the OMT, between 1999 and 2010 the international flow of tourism in the world registered a growth of 49%, knocking the mark of 935 million trips in 2010, with an estimated 1.6 billion in 2020. Figure 1 illustrates the growth of the sector over the analyzed period.
<figure><img src="image_2.png" /></figure>

Source: [2]

The same survey by [2] provides important data from tourism sector in Brazil, where, in the same period, foreign exchange earnings have more than tripled from U.S. $ 1.81 billion in 1999 to $ 5.92 billion in 2010.

The Health Pole of Teresina has shown steady growth in recent years, becoming a regional reference center. A first diagnosis made by the Union of the Hospitals of Piauí shows that 30% of attended clients come from six other states of the federation, generating employment and income for the city [3].

The beginning of a health cluster development can be observed with the formation of a production chain and linked services, bringing benefits in terms of cost reduction, quality improvement, training of qualified manpower, capital attraction and increase in employment and income. Such benefit extends to the Private Health Network, increasing its share in serving the population through an investment which reached US $ 47,5 million in 2011 [4].

With this, the main objective of this article is to demonstrate the contribution of health tourism as a tool for the opening and growth of companies, as well as a mechanism to help to ensure that companies efficiently assume their social function, contributing to the improvement of life quality in that region and being immediate inducer of Teresina's growth factor.

Another important point that this paper seeks to demonstrate in that tourism focused on health, especially in this case, allows such activity to be an aspect of good practice as part of the World Tourism Organization's Code of Ethics (ESDT) [5], as a principle for sustainability, because it avoids unnecessary travel. Indeed, the region of Teresina is located in the Northeastern Brazil, in an area where lacks several resources and requires internal migration for various reasons, including health.

## 2 Methodology

Using the proposition of [6], it is possible to classify this research in two respects: by the final purpose and by the means of investigation.

As for the means of investigation, this research has an important bibliographic emphasis. Bibliographical because it holds a review of the available literature on the subject; a systematic survey of books, journal articles, theses and dissertations, and other publications on the subject, aiming to theoretically justify the thesis and help to analyze the collected data.

As for the purpose, the research is exploratory, descriptive and applied. Exploratory because there is little accumulated knowledge about the subject
influencing a determined sector such as it is in Teresina health sector. There are few published works on the identification of variables in Tourism Health and the composition of clusters in the city influenced by Tourism Health.

This research is also descriptive, as it includes the collection and display of data representative of a given situation or phenomenon. According to [7], the purpose of this type of research is "to discover and observe phenomena, trying to describe them, classify them and interpret them." Also in respect of the purpose, it can be classified as applied, since it has practical purpose and is motivated by the need to demonstrate how Health Tourism in a particular geographical area of the country may lead to generation of employment and income.

# 3. Literature review

## 3.1 Definition of Tourism and its ratings

Tourism can be defined as a phenomenon that refers to a movement of people in their own country (domestic tourism) or crossing national borders (international tourism). This movement reveals elements, such as interactions, individual and group relationships, human comprehension, feelings, perceptions, motivations, pressure, satisfaction, notion of pleasure, etc. [8].

According to [9], the comprehension of the current touristic phenomenon shall necessarily goes through an analysis of the meaning of travelling throughout history. Usually motivated by economic, political or military reasons, trips are made by people to different regions

A trip is an action that comes from a context in which a determined time of history is inserted. Travelling is one of the components of the economic and social life, as well as of the world it is inserted. Each type of civilization ou society corresponds in a way to how they travel or welcome a traveller.

For [8], the anatomy of the phenomenon is basically composed by the knowledge of three elements: man (human element as performer of tourism), space (physical element, where the act is taking place), and time (temporal element consumed by the trip and the stay). These respresent the conditions for the existance of the phenomenon.

However, other characterizing factors distinguish tourism from the simple act of travelling. These factors are related primarily to the objective and temporary nature of the displacement, and the use of touristic services and equipments, most importantly the notion of pleasure and recreation.[10].

For[11], a revolution in traditional travelling concepts was performed by the touristic phenomenon since the 19th century, when protestant minister Thomas Cook opened the first tourism agency in England.

Some countries, such as Italy, France and Spain – former colonialist and military powers – were able to stabilize their post-war capital account to a point in which this activity builds a real industry, with proper state organs and specific legislation, that regulates different aspects of tourism, such as social, economic, commercial and cultural, with the objective of expanding the touristic industry.
## 3.2 Factors that influence touristic decisions

Every person is a potential tourist, but requires the act of travelling for tourism to exist. For that there are some conditions such as the will (animus) and the possibility [11]. The will can be originated by different causes, such as advertisements, status, habit, the physical, moral or intellectual convenience, seduction or interests in commerce, profit and health. Possibilities, however, involve factors that are out of the control of man, such as free time, money, transportation, among others.

Possibilities exist most commonly in higher social classes, therefore there is an association of privileged to tourism. Nowadays, however, with several facilities, social and popular tourism became more common.

Considering this, there are many reasons that lead a person to be a tourist, for example: business, religion, health, culture, education and pleasure.

According to [12], the needs that tourism satisfy can be varied, for the causes are as diverse and subjective as the human body and soul's needs. The touristic motivations or subjective causes, can be classified as primary and secondary causes; direct and indirect; near and remote; individual and social.

* Primary and Secondary Causes

The tourist, when he decided to travel, this usually has more that one cause. There is, however, one that is the most important and determines the trip, called primary. However, there are also secondary causes of less importance. For example, a person who takes a peregrination trip has as his primary cause the spiritual grace, but also has secondary causes, such as the possibilities of knowing new places, visiting famous monuments and resting.

* Direct and Indirect Causes

A trip can occur due to an invitation or the desire to meet new places. Although, it can also involve indirect causes such as the habit of travelling or the social and economic level of the traveller.

* Near and Remote Causes

An example of near cause of a trip is an advertisement of a travel agent, and a remote cause could be the memory of a previous trip.

* Individual and Social Causes

Individual causes act on the person's decision to travel, while the social causes are influenced by some sector of the population. Practicing a sport may be an individual cause, and fashing trends or ideological affinities are social causes.

The search for the healing of a disease is, of course, the primary, direct, near and individual cause that moves Health Tourism, but often other causes come together and reinforce its economic and social importance.

## 3.3 Tourism classification

Tourism can be classified due to its modalities – Internal, External, Receptive, Intermediate and Quantitative – and about type – Vacation, Cultural, On Business, Sportive, Health and Religious [13]. The Health Tourism, also known as Therapeutic
Tourism, refers to the set of activities which achieve good physical and psychic conditions [7].

In relation to the city of Teresina and its health center in context, the modality to which it belongs, according to [7], is of a regional receptive center for people in health treatment with internal characteristics, because the temporary population flow is typically regional and from the country.

The internal relationship between tourism and economic science is expressed in terms of the touristic contribution to the economic development. With respect to this, [8] wrote:

"Tourism is a phenomenon that moves capital of one country to the other, by people who dislocate to other places in order to consume a product or stay. They are potential consumers of a complex of goods and services that is offered with a specific objective. Tourism, through consumption and investment, affects different sectors of the economic system of a country, and it is believed that its multiplied effect is higher than the one observed in other sectors of economy, such as the industry...".

According to [14], the advantages of tourism for a receptive country or state are:

* Increase in revenue and currency through selling services and goods;

* Creation of new revenues in various economic sectors;

* Low investments in comparison with profit income;

* Integration between different regions and populations, with diverse habits, gestures and languages.

It is possible to verify, with the citation above, that tourism does not only bring currency to a region or country, but also provides integration between different cultures, achievement that is one of the most important in a modern society and civilized world.

The economic impacts generated by a touristic activity may be characterized, as by [15], in:

* Direct impacts: the total profit of touristic sector as a direct results of the product investment;

* Indirect impacts: the total income generated by the investment made by tourism sectors, in goods and services offered by the economy.

* Forced impacts: as a result from indirect and direct impacts of tourism, representing the levels of income increased in the economy; furthermore, part of this profit will be invested in goods and services produced internally, and represent the forced impact.

## 4. Case study

Teresina, a city with 836.475 inhabitants, has a complete network of health services, composed by a number of hospitals, clinics, policlinics, mixed units, and health posts and centers that belong to the state, to the city and to the private initiative, which makes the capital of Piaui an important medical center of various areas

Due to these characteristics, as well as its location, 40% of the medical consultations are represented by people from the North and NorthEast, who travel to Teresina for medical care.

This is an increasing tendency in the city, not only due to the fact that there is a Medical College well known in the country, but also because of the high quality in
services by the health professionals. In Teresina, today, surgeries such as heart and organ transplants, and neurologic surgeries, among others, are performed.

Due to its good location, Teresina became a so important Northeast Medical Center. In last years, the capital of Piauí has been highlighted nationally, being the health center that receives the higher number of patients from other regions [16].

The investments in the area are very expressive and, lately, the clinics have doubled in number. According to the city's statistics, there are 663 health establishments; 8 are hospitals, 181 are medical clinics and 170 are practices.

Table 1 shows the importance of the Health Center in the city of Teresina, as a generator of profit and jobs.

<table><caption>Table 1 - Establishments on Health Center by sub-area
Source: [3].</caption><thead><tr><th colspan="5">establishments located on the health center, by sub-area</th></tr><tr><th>Sub-area</th><th>Center Area</th><th>Peripheral area I</th><th>Peripheral area II</th><th>Total</th></tr></thead><tbody><tr><td>Hospitals</td><td>5</td><td>1</td><td>2</td><td>8</td></tr><tr><td>Clinics</td><td>163</td><td>14</td><td>4</td><td>181</td></tr><tr><td>Practices</td><td>133</td><td>36</td><td>1</td><td>170</td></tr><tr><td>Laboratories</td><td>24</td><td>3</td><td>-</td><td>27</td></tr><tr><td>Blood stock</td><td>1</td><td>-</td><td>-</td><td>1</td></tr><tr><td>Emergency</td><td>1</td><td>-</td><td>-</td><td>1</td></tr><tr><td>Maternity</td><td>-</td><td>1</td><td>1</td><td>2</td></tr><tr><td><strong>Direct activities</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Subtotal</td><td>327</td><td>55</td><td>8</td><td>390</td></tr><tr><td>Material/Com./H</td><td>3</td><td>2</td><td>-</td><td>5</td></tr><tr><td>Medical schools</td><td>2</td><td>-</td><td>-</td><td>2</td></tr><tr><td>medical companies</td><td>39</td><td>15</td><td>7</td><td>61</td></tr><tr><td>Health insurance adm.</td><td>4</td><td>2</td><td>-</td><td>6</td></tr><tr><td>Hostels and hotels</td><td>28</td><td>-</td><td>9</td><td>37</td></tr><tr><td>food commerce</td><td>108</td><td>23</td><td>-</td><td>131</td></tr><tr><td>Social assistance unit</td><td>1</td><td>-</td><td>-</td><td>1</td></tr><tr><td><strong>Indirect activities</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Sub Total</td><td>185</td><td>43</td><td>17</td><td>245</td></tr><tr><td><strong>TOTAL</strong></td><td>512</td><td>97</td><td>24</td><td>633</td></tr></tbody></table>

The chart above shows how the Health Center in Teresina has an expressive number of direct and indirect activities, connected to the health sector of the city. It is noted the beginning of health clusters, with the development of a productive chain with interconnected services, that brings benefits in terms of cost reduction, qualification, jobs, and academic formation. According to the regional station of work in Piauí, more than 15,000 jobs are directly involved in the health sector in Teresina.

In Teresina there are two factories of medicine and hospitalar materials: one of serum and one of masks, robes and gloves.

It is very significant that Teresina has respectively 181% and 280% more health establishments per 1,000 inhabitants than the other nearby state capital, as shown in
<table><caption>Table 2, what is clearly a consequence of the existence of a health pole established in the Piauí State capital city.</caption><thead><tr><th>INDEXES</th><th>CITIES</th><th>TERESINA</th><th>SÃO LUÍS</th><th>FORTALEZA</th></tr></thead><tbody><tr><td>Number of Health Establishments</td><td></td><td>633</td><td>283</td><td>531</td></tr><tr><td>Number of Inhabitants (August 2013 projections)</td><td></td><td>836.475</td><td>1.053.922</td><td>2.551.806</td></tr><tr><td>Health Establishments/1000 Inhabitants</td><td></td><td>0,76</td><td>0,27</td><td>0,20</td></tr></tbody></table>

<caption>Table 2 – Table comparing Piaui and other nearby capital.</caption>

Source: [16],[17].

Another factor that transforms the capital of Piaui in a Health Reference Center, was the development of the human resources in all levels: graduate, technician, auxiliary and administrative. In the graduate level, the courses offered are medicine, odontology, nursery, nutrition, social service, physical therapy, pharmacy, psychology, radiology and nutrition; in technician level the options are auxiliary in technical nursery, radiology, dental hygiene and consultant in odontology practice.

## 4. Conclusion

Tourism is generally understood as an activity involving leisure, but can also be associated to other finalities. In this article in particular, the importance of tourism was shown regarding health motivations, and how its management caused profitable and beneficial results to a city located in one of the poorest states in Brazil, away from the sea and lacking specific attractive leisure touristic motivations.

A combination of factors, such as geographic localization, opportunity vision and enterprise, made a new tourism center emerge, regarding health issues, which also represents the development of various activities that generate jobs, income, profit and development.

The main aim of this article was to describe this phenomenon, showing that good results may be obtained in unexpected places and conditions, as for a vision and a wish exist which can find possibilities for entrepreneurship in these situations.

It is intended that the example examined in this article can be an example and incentive for other governments and entrepreneurs in the sense that they can develop innovative projects of real utility in places that, in principle, present little or no conditions for these realizations.
## References

1. BUCCELLI, D.O.; ESPUNY, H.G.; CAVALEIRO, J.C.; COSTA NETO, P.L.O.; LOPES, R.A.; ROMANO, S.M.V. Education mediated by technology: strategy to spread high school learning in Piauí State, Brazil. APMS-2013. State College, PA, USA, 2013.

2. WTO – World Tourism Organization – Fecomercio Tourism and Business Council, São Paulo. June 2011.

3. TERESINA MUNICIPALITY Agenda 2015 Review, Teresina, 2010.

4. SINDHOSPI – Piauí Hospitals Syndicate, 2010.

5. ESDT. Ethics and Social Dimensions of Tourism. TOURISM WORLD ETHICS CODE. Avaliable at:< http://ethics.unwto.org/sites/all/files/docpdf/portugal.pdf>. Acessed: March, 18, 2014.

6. VERGARA, S. C. Methods of Research in Management. São Paulo: Atlas, 2010.

7. RUDIO, F. V. Introduction to the Scientific Research Project. Petrópolis (RJ): Vozes, 2002.

8. WAHAB, S-E. A. Introduction to Tourism Management. São Paulo: Pioneira, 2008.

9. CASTELLI, G. Hospitality: Innovation in Management in Service Organizations. São Paulo: Saraiva, 2010.

10. DORNELAS, J. C. A. Entrepreneurship. São Paulo: Elsevier, 2010.

11. OLÍMPIO, B. N., Introduction to Tourism Study. São Paulo: Atlas 1984.

12. ARRILAGA, J. I. Introduction to Tourism Study. São Paulo: Atlas, 2004

13. ANDRADE, J. V. Tourism: Fundamentals and Dimensions. São Paulo: Ática, 2008.

14. BAPTISTA, M. Tourism: Strategic Management. São Paulo: Atlas, 2004.

15. LAGE, B. H. G.; MILONE, P.C. Economy of Tourism. Campinas: Papirus, 2010.

16. MINISTRY OF HEALTH OF BRAZIL National Register of Health Care Facilities. Avaliable at:< http://cnes.datasus.gov.br/Lista_Tot_Es_Município.asp?Estado=22&NomeEstado=P%CDAUI>. Acessed: March 18, 2014.

17. IBGE – Brazilian Institute of Geography and Statistics. Avaliable at:< ftp://ftp.ibge.gov.br/Estimativas_de_Populacao/Estimativas_2013/populacoes_estimativas_municipios_TCU_31_10_2013.pdf>. Acessed: March 18,2014.