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Ranking of Sustainable Medical Tourism Destinations in Iran: an Integrated Approach Using Fuzzy SWARA-PROMETHEE

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Ranking of Sustainable Medical Tourism Destinations in Iran: an Integrated Approach Using Fuzzy SWARA-PROMETHEE sustainability Article Ranking of Sustainable Medical Tourism Destinations in Iran: An Integrated Approach Using Fuzzy SWARA-PROMETHEE Peiman Ghasemi 1 , Amir Mehdiabadi 2 , Cristi Spulbar 3 and Ramona Birau 4,* 1 Department of Industrial Engineering, South Tehran Branch, Islamic Azad University, Tehran 1584743311, Iran; [email protected] 2 Department of Management, South Tehran Branch, Islamic Azad University, Tehran 1584743311, Iran; [email protected] 3 Faculty of Economics and Business Administration, University of Craiova, 200585 Craiova, Romania; [email protected] 4 Faculty of Education Science, Law and Public Administration, Constantin Brancusi University of Targu Jiu, 210135 Targu Jiu, Romania * Correspondence: [email protected]; Tel.: +40-767-970-777 Abstract: Today, medical tourism is one of the fastest growing sectors of the tourism industry around the world. Medical tourism can contribute to the sustainable development and economic dynamism of countries. Therefore, in this study, we prioritize the world’s leading countries in medical tourism for Iranians. First, five main criteria and 20 sub-criteria were selected, which are the reasons for choosing a country as a medical tourism destination. In this paper a combined fuzzy SWARA-PROMETHEE approach was used to prioritize tourism destinations. The acronym PROMETHEE stands for Preference Ranking Organization Method for Enrichment Evaluation method and represents an useful MCDA (Multi-Criteria Decision Analysis) tool. On the other hand, SWARA acronym means Step-wise Weight Assessment Ratio Analysis. The criteria were weighted using the fuzzy SWARA approach. In the following, using the PROMETHEE approach, we prioritized eight countries as tourism destinations, then we identified criteria related to sustainability Citation: Ghasemi, P.; Mehdiabadi, A.; Spulbar, C.; Birau, R. Ranking of of medical tourism destinations and prioritized medical tourism destinations using these criteria as Sustainable Medical Tourism the contributions of this paper. The weights obtained for criteria “Abilities of skilled staff,” “Applied Destinations in Iran: An Integrated medical equipment,” “Marketing capability,” “Type of service provided,” and “Application of Approach Using Fuzzy information and communications technology” were 0.176, 0.232, 0.108, 0.395, and 0.089, respectively. SWARA-PROMETHEE. Sustainability The results show that medical tourism destination priorities for Iranians are India (Phi = 0.1396), 2021, 13, 683. https://doi.org/ Malaysia (Phi = 0.1128), Panama (Phi = 0.0976), Mexico (Phi = 0.0790), Singapore (Phi = 0.0096), 10.3390/su13020683 Taiwan (Phi = −0.0442), Brazil (Phi = −0.1747), and Costa Rica (Phi = −0.2196), respectively. Negative Phi values indicate below average performance of those countries and positive Phi values indicate Received: 9 December 2020 above average performance of those criteria. The results indicate that countries with negative Phi Accepted: 8 January 2021 values should be strengthened relative to the improvement of some criteria. Published: 12 January 2021 Keywords: medical tourism; fuzzy SWARA; PROMETHEE; sustainable development; consumer; Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- medical tourism destinations ms in published maps and institutio- nal affiliations. 1. Introduction In recent decades, especially during the last 30 years in the application of new meth- Copyright: © 2021 by the authors. Li- ods in the sub-sectors of the tourism industry, many efforts have been devoted to the censee MDPI, Basel, Switzerland. sustainability of such activities. Until the late 1970s, tourism was introduced as a golden This article is an open access article activity without drawbacks, and its positive consequences, especially its economic benefits, distributed under the terms and con- were always emphasized [1]. Numerous research findings and reports since the 1980s have ditions of the Creative Commons At- confirmed the adverse environmental, social, and cultural consequences of tourism. In tribution (CC BY) license (https:// the 1990s, in line with the sustainable development paradigm, traditional approaches to creativecommons.org/licenses/by/ tourism development were challenged, and with a simultaneous emphasis on the favor- 4.0/). Sustainability 2021, 13, 683. https://doi.org/10.3390/su13020683 https://www.mdpi.com/journal/sustainability Sustainability 2021, 13, 683 2 of 32 able and unfavorable consequences of tourism, the movement from mass tourism to the approach to sustainable tourism development began [2]. Tourism as well as medical tourism can be sustainable if developed and managed, considering visitors/medical tourists and local communities/health care centers [3]. This can be achieved through community engagement, congestion management, reduction of seasonality, careful planning that respects the limits of capacity and the specificities of each destination, and product diversification [4,5]. Medical tourism is a type of tourism that happens in order to maintain, improve, and regain the physical and mental health of an individual in a period of more than 24 h and less than a year [6]. According to Connell (2013) medical tourism can be perceived as a vacation that entails traveling into foreign countries to access a wide range of health services [7]. Zarei et al. [8] defined medical tourism as an individual’s travel for treatment (whether through medical intervention or the use of natural resources), rest, and maintaining physical health. This travel can be voluntarily or on the advice of a doctor [9]. Factors that include improving medical standards in developing countries, global- ization and free trade in health care services [10], development of the Internet, and the emergence of communication companies that act as intermediaries between international patients and hospital networks and provide patients with easy access to information and prices, together with advanced technologies created with new care services have paved the way for the rapid growth of medical tourism [11]. In addition to the above, issues such as demographic changes in developed countries along with increasing problems in their health care systems such as long queues of patients, high costs of health services, and high rates of non-insurance coverage cause patients to travel from these countries to receive high quality and low cost health services [12]. Hadian et al. [13] defined medical tourism as a patient’s travel to receive healing or disease aggravation preventive services outside the usual living environment for a minimum of one day and a maximum of one year, adding that the travel of healthy people who accompany the patient during this period should be considered a part of medical tourism. In general, medical tourism is any travel to promote health (for an individual or one of their family members) [14]. With global revenues of about USD 20 billion in 2005, it is one of the world’s largest industries [15]. The medical tourism market included 19 million trips with a total value of USD 20 billion in 2005 [16]. According to the latest report, global medical tourism market was valued at approximately USD 65.5 billion in 2019 [17]. The increase in the number of uninsured people in Western countries as well as the increase in health care costs has led people to choose treatment abroad. Many countries are experiencing high growth in medical tourism [18]. As an interdisciplinary approach, Ganguli and Ebrahim (2017) revealed that medical tourism, which is a rapidly growing market, has been recognized by many countries as a potential sector for economic diversifi- cation [19]. The World Tourism Organization (WTO) specifically defines medical tourism as: Use of services that improve or enhance a person’s health and well-being (using mineral water, weather, or medical interventions) in a place outside the person’s residence that lasts longer than 24 h. The global motto of health tourism is facilities and services at the level of the first or advanced countries of the world, and prices and costs at the level of developing countries and the third world [20]. The concept of health tourism was originally introduced by the International Union of Tourist Organizations (IUTO), which is the predecessor of UNWTO, in 1973. In other words, IUTO provided the following definition for health tourism, such as: “the provision of health facilities utilizing the natural resources of the country, in particular mineral water and climate” [21]. According to UNWTO/ETC’s report on health tourism launched in 2018, health tourism “covers those types of tourism which have as a primary motivation the contribution to physical, mental and/or spiritual health through medical and wellness- based activities” [22]. Sustainability 2021, 13, 683 3 of 32 By 2025, it is predicted to grow to 500 million travels, or 10% of global tourism [23]. The number of medical tourists is also expected to increase exponentially [24]. For example, in Taiwan the number of medical travelers is expected to increase to 777,523 by 2025 [25]. In developed countries, each of the following issues can motivate people (demand side) to receive these services in other countries despite some problems such as lack of insurance coverage and the high cost of treatment [26]. Connell (2013) argued that familiarity with destinations represents a facilitator for potential medical tourists to select a particular country [7]. In addition, Heung et al. (2010) identified certain advantages of the medical
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