The Registry Doesn’t Bring Patients
In 2024, we voted the medical tourism seal into law again. What’s missing is the signature that activates it — and something more serious: a reason for In 2024, we voted the medical tourism seal into law again. What’s missing is the signto want it.
Obstacles 1, 3 and 5 from the series “Seven Obstacles to Health Tourism.”
Previous issue: linkedin.com/pulse/επτά-εμπόδια-στον-τουρισμό-υγείας…
In the previous issue, I set out seven obstacles to growing health tourism. I’m taking three of them together here, because they don’t get solved separately: the registry and the seal, investment incentives, and incentives for attracting international patients.
Everything here is based on published Government Gazette (ΦΕΚ) notices and public data.
A registry, on its own, does nothing
Let me start from the beginning, because this is where the conversation always gets stuck.
A list of clinic names has never brought a patient to any country. It never will. A German patient doesn’t go looking for Greek registries. Their insurer doesn’t even know these registries exist.
The registry has value for exactly one reason: it’s the only way the state knows who it’s talking to. Without it, the state can’t give an incentive to anyone, can’t promote anyone under the country’s name, and can’t sign anything with a foreign insurance fund.
It’s the recipient list. It is not the gift.
And that’s exactly the problem with the conversation we’ve been having for the last twelve years. We keep talking about the list. Nobody has ever talked about the gift.
The question that matters isn’t “when will the registry happen.” It’s: the day after, what does the state give me to invest?
I’ll devote most of this piece to that question. First, though, quickly, the seal — because nothing can be tied to something that doesn’t exist.
The seal: yes, and quickly
What’s missing today.
The state knows which clinics operate legally. They’re licensed, inspected, on record. That question is already answered.
What’s not answered is the second question, and it’s the one the foreign buyer actually asks: is this clinic ready for a patient coming from Germany? Does anyone speak their language? Will they get a final price before they travel? Who follows up with them once they’re home? If something goes wrong, which insurance covers a foreign national?
An operating licence says nothing about any of this. It proves you’re legal, not that you’re ready.
The law establishing the seal has been written and rewritten four times. In 2013, a Special Seal was introduced with a registry at the Greek National Tourism Organisation (EOT). In 2014, it was rewritten. In 2018, the seal was struck from the text, leaving only a database at EOPYY. In 2024, under Article 15 of Law 5121/2024, the whole mechanism came back: a registry at the Ministry of Tourism, a Special Seal valid for three years, regular inspection, and revocation.
None of the four versions was ever activated. Today, the Joint Ministerial Decision that would activate the fourth version is still pending. There’s no indication it has been issued.
There’s also a technical problem, which I’ll cover briefly since it mainly concerns whoever drafts the decision. As a condition of registration, the law requires “accreditation of the unit… by international medical-service accreditation systems.” If that’s read as full hospital-wide accreditation from the major international bodies, then the first step is also the last one. It costs tens to hundreds of thousands of euros and takes up to two years to prepare for. The dental centre in Crete, the IVF unit in Thessaloniki, the diagnostic centre in Patras — none of them ever get in.
But the solution doesn’t need a new law — it’s already inside the existing one. Because the law doesn’t say one thing. It says two things, in two different places.
In the registration requirement, it asks for “accreditation of the unit… by international medical-service accreditation systems.”
In the authorisation clause for the decision — where it sets out exactly what the Joint Ministerial Decision is to regulate — it says: “the accreditation of medical tourism services, in accordance with international standards.”
Two words, two mechanisms — and they are not the same thing. An accreditation system is a body that comes in, assesses your unit, and accredits it. A standard is a published set of requirements, against which an auditing body certifies you.
In other words, the legislator didn’t lock the sector into one mechanism. It named both, and gave the decision authority over both.
It also says a provider is any entity offering such services “by department or unit” — so it’s the international-patients department that can be assessed, not the whole hospital.
Those three elements together give us the solution, with no legislative change at all: two tiers. A base tier that any serious unit can reach, and a higher tier for those with full accreditation.
Both standards and systems already exist in the market. But we need to clear up something we all get confused about, because otherwise the conversation always ends up at the same dead end.
There isn’t one scale running from cheap to expensive. There are two different questions.
First question: is this clinic well organised? That’s answered by the European quality standard for health services, EN 15224 (adopted in Greece as ELOT EN 15224) — the lightest tool available, with accredited Greek certification bodies and a three-to-six-month timeline. But it has a blind spot: a perfectly well-run Greek unit that has never seen a single foreign patient passes it easily.
Second question: can it actually take in someone who arrives by plane? That’s answered by ISO 22525, written specifically for medical tourism: what information you give before the trip and in what language, what the written quote says and what it doesn’t cover, who picks up the file when the patient gets home, how you handle a complaint that comes from another country. It covers facilitators too.
Those two are the law’s “standards.” And there is, third, its “systems”: international accreditation programmes, which answer both questions at once. That’s where a real cost scale exists — from mid-scale programmes focused specifically on managing international patients, affordable for a mid-sized unit, all the way up to full hospital accreditation — the heaviest and most expensive tool on the market, costing tens to hundreds of thousands of euros and up to two years of preparation.
It’s the mid-tier programmes that matter here, because they accredit the unit — doing exactly what the law asks for — without the cost of the top tier.
And remember exactly how the law phrases it.
It speaks of “systems,” plural. It names none of them. It doesn’t point to any specific body.
That’s not an omission. It’s room to manoeuvre.
Because alongside the heavy international schemes, there are also lighter accreditation programmes built specifically for managing international patients: lower cost, less time, achievable for a mid-sized unit. And they too accredit the unit — doing exactly what the law asks for. Nothing in its text rules them out.
And the international standard?
ISO 22525 was written specifically for medical tourism, through an open standardisation process. It isn’t free — it’s purchased, like any ISO standard.
And it exists, is being issued, and is being audited today. In Spain, certificates have been issued since 2022 — there’s a clinic in Ibiza with a certificate valid through 2028. In the Dominican Republic, a state body granted it in February 2026. India has published a complete certification scheme.
What we didn’t find — checking, in August 2026, the published scopes of accreditation bodies in Spain, Italy, Britain and Colombia — is a single body with an accredited scope covering it.
The clearest example is Spanish. The body issuing ISO 22525 certificates is itself accredited. In the technical annex to its accreditation, you’ll find hotels, spas, beaches. You won’t find medical tourism.
The reason isn’t technical, and it has nothing to do with the standard’s quality. Accreditation isn’t granted to a standard. It’s granted to the implementation of a scheme — audit rules, inspector qualifications, decision-making procedure, oversight. A standard is not a scheme. And a scheme is submitted by whoever owns it. For ISO 22525, nobody has done that yet.
If anyone knows of an accredited scope we missed, I’d genuinely like them to show me.
So the decision has three possible paths, and they are not equivalent.
The path open today: explicitly accept the lighter accreditation programmes too. It rests squarely on the text of the law. One signature, nothing more.
The path that complements it: have the decision itself define the criteria for international patients, using ISO 22525 as a technical basis. It has a virtue the other two lack — it borrows content, not a certificate, so it doesn’t hand anyone an institutional monopoly.
And the path that needs one corrective sentence: if we want certification under the European health-quality standard to count instead of accreditation, a ministerial decision can’t do that. The requirement is written into the law itself. It needs one clause in the next bill.
The first two can happen now. And the first two are enough to get the registry started with members.
These are the easy parts, and they should already have been done. The hard part starts now.
The day after
Put yourself in a clinic owner’s shoes.
You tell them: get certified. You’ll pay for the audit. You’ll change your procedures. You’ll hire someone who speaks German. You’ll set up phone follow-ups for patients who left two months ago.
They ask you: and then what?
If the answer is “you’ll be on a list,” the conversation is over. And they’re right.
Look at how others answer that question.
Turkey started the same year we did, in 2013. In 2017, it made certification mandatory for every clinic and every facilitator. In 2019, it founded a state company, USHAŞ, and built a national platform.
And it gave this: a 50% deduction on profits from health services to non-resident patients. It raised that to 80%. Today it covers the full amount of those profits.
But it isn’t just the tax, and that’s the part we usually leave out. Medical tourism is a “priority sector” there in the investment-incentive system, meaning it gets the top incentive tier anywhere in the country: VAT exemption on equipment, customs exemption, reduced corporate tax, employer social-security contributions covered, and land grants. And on the export side, the relevant ministry subsidises the cost of promotion in foreign markets, the cost of an overseas office, and the cost of certification itself.
Hold onto that last point. The two things I’ll ask for below, Turkey already gives. I’m not imagining something original here — I’m asking for something that’s already working right on our border.
Malaysia has run a state council under its Ministry of Health since 2009, with membership limited to accredited units. It gave two things: a full deduction on eligible investment spending for units targeting health tourism, and an enhanced deduction for the cost of certification itself. In other words, it paid for the ticket of admission it was asking for.
Dubai built a health free zone: zero tax, full foreign ownership. It now has more than 170 units there.
Three countries, three different tools, one logic. None of these states asked the private sector to invest alone. They each paid part of the bill too.
What do we give today? Nothing.
And the result shows. According to the Bank of Greece, receipts from health-purpose travel were €61.7 million in 2022, €37 million in 2023, €30.6 million in 2024, and €19.9 million in 2025. A third consecutive year of decline. Roughly 68% lower over three years, while the market around us keeps growing.
We’re not losing because we lack good doctors. We’re losing because nobody has a reason to invest in helping the world find them.
And something that isn’t about money
There’s a second category of benefit that we discuss even less: market access. Who, in the end, can actually pay a Greek clinic for a foreign patient?
There are four such paths, with very different obstacles, and one common precondition: a foreign health ministry does not contract with a private company’s list. It wants an official register, with criteria a state guarantees. That is the one point where no private scheme can substitute for the state seal.
It’s the sixth of the series’ seven obstacles, and I’ll cover it in full in a future issue.
What needs to be on the table
Three things. I’m listing them in order of difficulty, easiest first.
1. Refund the cost of certification.
The provider pays for the audit, the preparation, the consultants, the process changes. An enhanced tax deduction — counting, say, at double value — or a direct percentage subsidy.
Why I put it first: it’s spending that happens in Greece, on an invoice, and it doesn’t depend on how many foreign patients you end up treating. It’s an investment in capability, not a reward for sales. We’ll see in a moment why that distinction decides everything.
2. Make the two investment laws actually work.
Here we have two laws that already say yes, and two different problems.
The Development Law (Law 4887/2022) explicitly keeps “health tourism and medical tourism investment plans” eligible. But that same law, Article 129 §18, says the terms of inclusion will be set by ministerial decision. There’s no indication it has been issued. The result: under no scheme announced so far is there a route for a medical tourism clinical unit. Even the general scheme accepts only narrow categories in health — rehabilitation centres, disability care homes, nursing homes. For four years, in other words, an investor has had nowhere to file an application.
The Strategic Investments Law (Law 4864/2021) is a different case, and it’s worth clarifying because we often mix the two up. It names medical tourism as a priority sector, alongside artificial intelligence and biotechnology. The threshold is twenty million euros instead of the seventy-five that generally applies, with no requirement for new jobs at all.
This path isn’t closed. No decision is pending. An investor can file tomorrow.
But it has a different problem: the law doesn’t define what a medical tourism unit actually is. It lists sectors by name, not by activity code. There’s no test anywhere that says when a clinic counts as a medical tourism unit and when it’s just a clinic. The Inter-Ministerial Committee decides, case by case.
So an investor considering putting in twenty million euros doesn’t know, before filing, whether they’ll qualify. And nobody commits twenty million euros on a judgement call.
So one law is locked: the decision is missing. The other is open but opaque: the definition is missing. And the same thing solves both, because the registry is exactly the definition that’s missing.
Watch the scale too. The twenty million threshold is for large projects. Neither law touches the three-million or eight-million-euro unit — the kind a Greek doctor or a mid-sized clinic would actually set up.
3. Spending on promotion abroad.
When a Greek clinic spends money to become known in Germany, that spending is treated like any other advertising expense. In substance, it’s an investment in exporting a service.
I put it third because it’s the hardest, and the reason is specific: of the three, it’s the only one European rules tie directly to foreign sales. In the next section I explain what that means and what room is left.
What the EU allows, and what it doesn’t
You might say: we’re in the EU, this kind of thing isn’t allowed.
It is allowed. But it has to be drafted correctly, and there’s exactly one distinction that decides it. I’ll put it as simply as I can, because everything hangs on it.
First, two things we constantly mix up.
VAT is harmonised at EU level, and that’s usually where the conversation stops. It shouldn’t.
The EU directive exempts hospital and medical care from VAT — not only care from public bodies, but also from “other duly recognised establishments of a similar nature.” It allows member states to add conditions, but those conditions are optional. Greece applied them cumulatively. The result: private secondary and tertiary care units charge 24%.
Europe didn’t impose that. We chose it. And it’s worth revisiting, because healthcare isn’t a product like any other — it’s a public good, and the rate we currently apply to inpatient care doesn’t reflect that.
So there’s room for a proposal here — a national one, at that, without needing anything from Brussels. I’ll analyse this fully in a future issue.
Income tax isn’t harmonised. It remains a national competence. So, formally, Greece can legislate a deduction.
The obstacle lies elsewhere: in state-aid rules.
When a state gives a tax advantage to a specific sector, that counts as state aid. As a rule, the European Commission has to approve it first — unless it fits one of the ready-made exemptions. If the state skips that step and it turns out to be wrong, the aid has to be repaid with interest. And it’s the provider who received it that repays it, not the legislator who wrote it.
Now, the critical distinction, and there’s only one: what triggers the benefit.
If the incentive is triggered by spending you make in Greece — you buy equipment, train staff, pay for certification — we’re on well-tested ground. That kind of aid is granted constantly, across every sector.
If it’s triggered by who your customer is — a deduction because the patient came from abroad — we’re on dangerous ground. The two routes that let a state grant aid without asking Brussels both exclude aid tied to export performance.
Let me be precise about what I know and what I don’t. I’m not saying this is definitely illegal. Exactly where the line falls is a legal question, with its own case law, and it needs a formal opinion. What I am saying is that the risk is real, and it’s not worth taking when there’s another route to the same result. Turkey can do what it does because it sits outside this framework entirely.
That’s why the order I set out above isn’t arbitrary.
The cost of certification is spending in Greece. Clean.
Investment in infrastructure is spending in Greece. Clean.
Promotion abroad is exactly the kind of spending the rules view with the most suspicion. The route that exists today is narrow, and mainly covers SME participation in international trade fairs. If we want something broader, it needs to be designed with a lawyer from day one — not tacked on as a paragraph in a tax law in December.
The conclusion is simple. We’re not asking for a deduction on profits from foreign patients. We’re asking for an incentive on what a unit does to be able to take them in. Same goal. A route that holds up.
What we’re asking for
Plainly, because after twelve years it’s earned.
One signature for the seal. The law has existed since 2024. The decision is pending, and it needs to resolve the two-tier issue — otherwise it will build a registry with no members.
One signature for the Development Law. The law has said yes since 2022. The decision setting out how to actually get in has never been issued.
One definition. Which unit counts as a medical tourism unit. Without it, neither Strategic Investments works nor can any incentive be targeted properly. The registry supplies it.
And the incentives. They need a tax provision and work from all of us — but they can start with the cost of certification, which is the easiest, most immediate, and safest place to begin.
The first two can happen today, with no new law. The authorisation already exists in both cases, and it’s sitting unused.
And all of them need someone to treat them as their own job to finish.
It isn’t the legislation that’s missing
The seal tells the state who is ready. The incentives give the provider a reason to get ready. The investment framework funds the infrastructure that makes it possible. Today, none of the three actually works, and that’s not a coincidence.
I’ve written before that our sector isn’t short of vision or plans. Here that’s plain to see. We’ve voted the seal into law four times. We have never once given it to anyone, and we have never hung anything on top of it.
A registry doesn’t bring patients. What brings patients is what a provider does when they have a reason to do it. And that reason is either given by the state, or it’s given by no one at all.
I’m available to anyone working on any of this — the registry and the seal, the incentives, the investment framework.
