The cost-of-living crisis has left the medical tourism industry struggling to recover even after the lifting of pandemic travel restrictions.
For years, traveling abroad to clinics in countries like Hungary and Turkey has been an option for British and North American patients who face long waits, high costs, or both for dental and medical procedures at home.
Operators had hoped for a rapid bounce back after curbs on travel were lifted.
But inflation fuelled by soaring energy and food prices since the Ukraine war started a year ago has left people with little money to spare, especially for cosmetic procedures.
In Hungary, which borders Ukraine, the war itself is making foreigners wary.
Rising airfares and fewer flights - and the memory of last summer's travel chaos - are also putting off would-be patients, clinic operators, and analysts told Reuters.
For some trips, like those to Turkey, airline tickets can be twice what they were in 2019, according to WeCure, which specializes in medical tourism to large hubs like Turkey from countries like Britain.
WeCure said flights, ground transfers, and petrol now accounted for about 15% of the cost of its travel and treatment packages, roughly double their proportion pre-COVID, putting upward pressure on overall prices.
Some clinics, facing their own higher costs, have hiked charges. A hip or knee replacement at Nordorthopaedics in Lithuania is about 15% more expensive now than five years ago, the clinic told Reuters.
"There will be some trade-offs (for customers)," WeCure's CEO Emre Atceken said. "Instead of having a hair transplant. I'd rather pay my gas bills. I would rather pay my electric bills."
PROCEDURES ON CREDIT
To encourage clients, some clinic operators are offering pay-as-you-go options, while crowdfunding has sprung up as another source of support.
Atceken said WeCure is offering some customers payment in installments to stretch out the cost.
Lyfboat, an Indian company providing medical services for foreign patients, told Reuters it has collaborated with a fundraising platform called ImpactGuru to help patients pay for essential surgeries.
Some operators are targeting patients from Britain and Canada, where strained public healthcare services can mean long delays.
Linda Frohock, 73, from Staffordshire, said she delayed retirement, took out a bank loan, and used savings to travel to Budapest for dental implants.
She paid 8,000 pounds instead of the estimated 32,000 pounds the procedure would have cost in Britain.
ACUTE VS ELECTIVE
The International Medical Travel Journal, published by market intelligence service LaingBuisson, estimates the medical tourism market is currently worth around $21 billion, less than pre-pandemic, although editor Keith Pollard warned data is poor.
With about 7 million medical travelers a year, the IMTJ sees annual growth of 5%-10% as realistic - far less than some projections.
Laszlo Puczko, who runs Budapest-based Health Tourism Worldwide, said clinics specializing in urgent procedures would weather the economic climate as even customers feeling the financial pinch will pay. But those that have competed on price for elective treatments like rhinoplasty will find it harder to survive, he and others said.
"An orthopedic surgery is something that you cannot postpone if you have severe arthritis and you cannot walk. It's a major, life-changing surgery," said Vilius Sketrys, who runs sales and marketing at Nordorthopaedics.
Bob Martin, 71, decided to pay around 18,000 pounds for new dental implants at Kreativ. A retired NHS nurse manager from Britain, Martin's adult teeth never came through and he has struggled for much of his life with dentures.
Patients who need vital dental work done will press ahead whatever the cost.