sustainability

Article Ranking of Sustainable Medical Destinations in : 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 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 (Phi = 0.1396), 2021, 13, 683. https://doi.org/ (Phi = 0.1128), Panama (Phi = 0.0976), (Phi = 0.0790), (Phi = 0.0096), 10.3390/su13020683 (Phi = −0.0442), (Phi = −0.1747), and (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 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 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 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 , 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 tourism industry such as: increasing gross domestic product (GDP), improving medical services, and generating foreign exchange [6]. The following are some of the reasons for medical tourism: Cost: The cost advantages of developed countries and new industrialized countries in the field of medical services have caused the emergence of this phenomenon [27]. The main direction of medical tourism can be from developed to developing countries or vice versa. People travel from developing countries to developed countries to use higher medical facilities and technologies. Also people travel from developed countries to developing countries due to the availability of cheaper medical services [28]. Growth in demand: In recent years, the demand for health care has increased in developed countries for reasons such as the aging population [29]. This issue lengthens the waiting time of patients. Insurance: Due to the high cost of , a large group of people in developed countries do not have this insurance. Lack of insurance coverage for many cosmetic is another reason for the increase in medical tourists [19]. In addition, medical tourism in developing countries (supply side) has increased for the following reasons: 1. Globalization and liberalization of trade in the field of health services have caused the rapid growth of medical tourism [30]. 2. The growth and expansion of airlines has made it possible to use medical services in remote destinations [31]. 3. The Asian financial crisis has led to seek new sources of income [19]. 4. Favorable exchange rate changes in the global economy have made Asian countries suitable destinations for tourism [32]. 5. Rapid improvement of equipment [33]. The leading countries in the field of medical tourism are as follows [34]: • Brazil: It is one of the oldest countries in medical tourism, which owes much of its fame to cosmetic , but non-cosmetic surgery has little history in Brazil. The first hospital to be accredited by Joint Commission International (JCI) standards outside the was a hospital in Brazil that received the commission’s certification. • Costa Rica: Recently, Costa Rica has made great efforts in the field of medical tourism and has been one of the leaders of this industry since 2007. Costa Rica currently has three JCI-accredited hospitals, all three of which are in San José. • India: One of the most important Asian countries in the field of medical tourism, with 22 hospitals, all of which have received JCI certification. Indian medical tourism is very popular in the world. Moreover, the main reason in attracting tourists to India is the relative cheapness of goods and services compared to other countries. • Mexico: A very attractive destination for medical tourists, especially Americans. Americans living in the southern states bordering Mexico, such as New Mexico, , or Texas, go to Mexico almost routinely to receive cheap medical treatment. • Panama: Amazing attractions, bilingual physicians, having international documents and standards, using the US dollar so the tourists do not need to convert their money. These reasons have made Panama one of the leaders in the international medical tourism industry. • Singapore: This country has several JCI-accredited hospitals. Singapore’s health stan- dards are very high. According to the World Health Organization, in 2000 Singapore had the sixth best health care system in the world, and the first in Asia. Sustainability 2021, 13, 683 4 of 32

• Taiwan: The of Taiwan officially announced its intention to make its coun- try a medical tourism center, and in 2007 the Taiwan Ministry of Health implemented a plan to raise the level of all medical services in the country. • Malaysia: Malaysia provides guests with the best medical facilities in terms of cost. Most Malaysian medical tourists are from Southeast Asia because the cost difference is very high, and in addition, people in Muslim countries prefer to go to Malaysia for treatment because of the Malaysian Islamic culture. Some other researchers argued that India, Indonesia, Malaysia, the Philippines, Sin- gapore, and many other countries market themselves as major destinations for medical tourism [35]. Al-Talabani et al. (2019) suggested that countries like UAE, India, and the Philippines are leading, emerging major health care destinations, consid- ering that health tourism represents at the moment a USD 100 billion global business, while this particular kind of tourism is currently experiencing an average growth rate of 25% [4]. In addition, Lunt and Carrera (2011) highlighted the fact that medical tourism is an interdisciplinary trend, important in various disciplines, including inter-institutional cooperation [36]. Documentary and field studies in the field of health tourism in Iran show that, al- though health tourism in Iran has long been the focus of tourists and foreign patients entering the country and in recent years its organizational and legal management has begun, it is undergoing its first development and is facing the challenges that have arisen following the general conditions of the country in order to achieve its worthy position. These challenges are as follows: A. Lack of a clear strategy and agency for health tourism at the international, national, and regional levels. Despite the introduction of tourism in the laws of the Islamic Republic of Iran as one of the pillars of economic development, the share and position of this sector in the economy is not fully understood and lacks a clear long-term strategy in dealing with domestic and foreign tourism applicants. Health tourism in Iran has more than 60 institutions and stakeholders, all of which, based on their organizational duties and powers in the field of tourism and health tourism, claim to participate in management and do not have a proper response. B. Lack of a comprehensive health tourism system, definition and formulation of laws, policies and programs. C. Lack of infrastructure, including communication infrastructure, training infrastructure for health tourism professionals, infrastructure of medical facilities and equipment, infrastructure for welfare and accommodation services of health tourists and their companions, legal infrastructure. D. Lack of a codified and strong monitoring system; different quality of public and private centers, especially in the field of service quality; and weaknesses and short- comings in the accreditation system. E. Weakness in process management and design of standard service packages that can be provided to health tourists, such as: uncertain price of services, especially in the private sector; lack of a program and system for alternative, traditional and herbal medicine; and lack of medical tourism insurance, non-acceptance of medical tourism insurance coverage. F. Lack of necessary private sector support from the government; lack of definition and explanation of the position of the private sector and the use of its many potentials; the tendency to governmentalize the issue despite previous unsuccessful experiences; and the weak role of private hospitals and trade unions. G. Lack of integrated information management systems (M.I.S); lack and delay in estab- lishing a system of registration, control, and statistics of health tourists; and lack of infrastructure and basic information of hospitals. H. Lack of a clear marketing system, the presence of brokers and intermediaries along with providing inappropriate services at different prices, lack of marketing insti- Sustainability 2021, 13, 683 5 of 32

tutions, lack of foreign marketing research, lack of overseas advertising system, insufficient knowledge of target markets, and poor marketing efforts. The purposes of this research study are to select and rank the medical tourism des- tinations for the Iranian people. Therefore, at first, the sustainable criteria of medical tourism destinations are identified. In the following, using the fuzzy SWARA method, the weights of the identified criteria are determined based on the decision of experts. After determining the weights of the criteria, the medical tourist destinations are prioritized using the PROMETHEE method. The contributions of paper are as follows: • Identify criteria related to sustainability in the subject of medical tourism destinations, • Prioritize medical tourism destinations using a fuzzy SWARA-PROMETHEE approach, • Investigating the strengths and weaknesses of medical tourism destinations based on sustainable factors, • Application of the model to a real-world case study in Iran. Therefore, the research questions are as follows: 1. What are the sustainable criteria for medical tourism purposes? 2. What are the medical tourism priorities of patients in Iran? 3. How to prioritize tourist destinations with a hybrid fuzzy SWARA-PROMETHEE method? 4. How does the prioritization of tourist destinations change with the change of sustain- able criteria weights? 5. Which tourist medical destination country has performed poorly or strongly in terms of criteria? This research is presented in five sections. In the first section, the introduction is mentioned. In the Section2, the literature review is mentioned. This section is divided to medical tourism, medical tourism and sustainability, and analysis methods sub-sections. The materials and methods are presented in the Section3. The results and discussions are described in the Section4. Finally, conclusions are presented in the Section5 of our research paper.

2. Literature Review The literature review section is divided into two parts, including medical tourism and analysis methods.

2.1. Medical Tourism Medical tourism is the most sensitive type of tourism among all types of tourism, because it is directly related to the life and health of the tourist. Although many countries in the world today offer health tourism services to earn money, the potential of a country in medical science and medical services, unlike recreational and , is cer- tainly not something that can only be achieved through construction and spending money. Therefore, identifying sustainable criteria for medical tourism destinations and prioritizing destinations can help patients to choose destinations tailored to their needs. Sustainable criteria cover all economic, social, and environmental dimensions. Therefore, identifying and prioritizing criteria can help tourism destinations to strengthen strengths and reduce their negative criteria [37]. Perkumiene et al. (2019) argued that sustainable medical tourism represents “an emergent and growing business worldwide, combining different and very specific purposes from pleasurable travel to sometimes-stressful services of health care” [3]. Lunt and Carrera (2011) suggested that medical tourism is related to the idea of a person traveling to a foreign country with the purpose of receiving medical procedures, with an emphasis on “clinical, surgical, and hospital provision” [36]. Kim et al. (2019) considered that medical tourism represents the phenomenon of traveling across national borders intentionally to access a variety of medical treatments, especially modern medical treatment [28]. Khan et al. (2020) suggested that international medical travel is defined as “the citizens of source country Sustainability 2021, 13, 683 6 of 32

travel to foreign destination hospitals with the sole purpose of obtaining necessary medical procedures and treatment” [38]. Gan and Frederick (2011) revealed that medical tourism agencies (facilitators) actually include the organizations specializing in arranging suitable foreign hospitals and treatment, transportation, and lodging during recuperation [39]. Moreover, Hall (2011) revealed the existence of certain interrelationships between different areas of health and medical tourism, including wellness and well-being tourism, dental tourism, stem cell tourism, transplant tourism, tourism, and xeno-tourism [40]. Some researchers [35] suggested that the concept of “medical tourists” includes those patients trying to avoid treatment delays and obtain timely access to health care. Kangas (2010) argued that terminology for medical travelers ranges from “medical tourists” to “medical exiles” [12]. Lee and Li (2019) argued that is related to traveling to different countries for disease prevention, injury, immunology, infectious diseases, and vaccination, while medical travel is used for health inspections and , and involves medical treatment, rehabilitation, and self-care [41]. On the other hand, Wu and Guo (2014) mentioned that most people choose to take a getaway out of town in order to relax, improve their physical fitness, and engage in social activities, because of the natural environmental factors, including sound, temperature, humidity, atmospheric pressure, air, light, and lack of crowds [42]. The World Tourism Organization (UNWTO) defines the concept of sustainable tourism as: “Tourism that takes full account of its current and future economic, social and envi- ronmental impacts, addressing the needs of visitors, the industry, the environment and host communities” [21]. Spulbar et al. (2019) argued that, naturally, every country in the world needs to exploit its tourism potential in order to attract foreign capital for sustaining tourism and the [43]. To increase sustainable tourism it would be advisable to provide an increased level of customer satisfaction in order to facilitate the fulfillment of significant expectations for tourists, while raising their awareness about sustainability issues and promoting sustainable tourism practices among them [21]. The following Table1 illustrates the difference between this work and the previous studies in literature. The literature review table is divided as follows: 1. Identify Criteria: In some articles, the criteria are identified by experts. In other articles, existing criteria or criteria of other researches are used. 2. Outranking method: A classical problem in the field of multiple-criteria decision- making (MCDM) is to build a preference relation on a set of multi-attributed al- ternatives based on preferences expressed on each attribute and “inter-attribute” information such as weights. Based on this preference relation (or, more generally, on various relations obtained following a robustness analysis) a recommendation is elaborated (e.g., exhibiting a subset likely to contain the “best” alternatives). 3. Fuzzy: Some studies consider data to be fuzzy to bring the problem closer to the real world, and others consider data Crisp. 4. Sustainability: Concurrent attention to social, economic, and environmental criteria is called sustainability. 5. Methods: These include a variety of mathematical or decision-making approaches. 6. Real case study: Some studies consider a real case study and others consider a numerical example. Sustainability 2021, 13, 683 7 of 32

Table 1. Literature review.

Paper Identify Criteria Out-Ranking Method Fuzzy Sustainability Methods Real Case Study Khan et al. (2020) [38] • Conceptual framework • Çavmak and Çavmak (2020) [44] • AHP • Perkumiene et al. (2019) [3] •• Conceptual framework Farzin et al. (2019) [45] ANFIS-SVR • Nilashi et al. (2019) [46] •• DEMATEL-F.TOPSIS • Kim et al. (2019) [28] • Conceptual framework • Lou et al. (2019) [47] •• AHP • Yıldız and Khan (2019) [48] • AHP • Arif et al. (2019) [49] TOPSIS • Mayakul et al. (2018) [50] •• Conceptual framework • NajafiNasab et al. (2018) [51] • SEM • Rezaeenour et al. (2018) [52] • AHP and TODIM • Karami et al. (2017) [53] •• AHP • MorovatiSharifabadi and • TOPSIS-SEM • AsadianArdakani (2014) [54] Tsaur and Wang (2007) [55] • F. AHP • This paper •••• SWARA-PROMETHEE • Source: Author’s own contribution. Sustainability 2021, 13, 683 8 of 32

Dreisbach et al. [56] discussed certain issues such as: cancer, tourism, and the relation- ship between tourism and health. In this study, a model was presented that could reflect and easily explain the need of these patients to go on vacation at different stages of the disease. During the course of the disease, people look for different ways of rehabilitation and comfort, such as alternative and complementary therapies and support groups. They may be able to access such help by going on vacation. Nilashi et al. [46] stated that medical tourists are guests of a that devotes its time to a specific medical activity, so it is a product of tourism and the health sector. They considered the people who come for treatment as guests who devote only part of their time to a specific treatment and may use the rest of their time for other activities. In this study, tourism was considered along with the health sector, and the welfare facilities of medical tourism were considered, but the type of facilities was not mentioned. Ahire et al. [57] examined the details of today’s medical tourism creation. They compared prices in developing and developed countries, examined the medical tourism attractions and the available facilities, and stated that medical tourism has been created to meet the needs of a number of people, mostly from developed countries. The main centers of tourism are developing and mostly Asian countries, including India. Medical accounts for 8.6% of India’s GDP. Medical tourism includes the largest foreign financial transactions for these countries, as well. The medical tourism industry generated about USD 5 billion in revenue for India in 2018. This amount of GDP was the highest income from medical tourism in the world in 2018 [57]. Hall (2011) argued that the development of international medical tourism is demon- strated to have potentially significant implications for global public health [40].

2.2. Medical Tourism and Sustainability Tourism is growing and developing very fast in the present era. Increasing demand in terms of quantity and quality can be considered the reason for this [3]. The laws and regulations of different countries indicate this [58]. However, it is very difficult to accu- rately define the types of tourism and the types of communications, information systems, and various services, other than from economic, social, and cultural perspectives [59]. Medical tourism is one of the most important and important types of tourism on which different countries cooperate bilaterally or multilaterally [3]. The economic benefits of medical tourism are many; governments, residents, and various businesses are beneficia- ries of this type of tourism. It can also reduce the cost of transporting and exchanging information [60,61]. Medical tourism is a kind of cultural confrontation between nations [62]; while they are considered tourists, they can travel long distances in order to receive a variety of medical services [7]. The medical tourist experiences the thrill of traveling and makes the best use of the potential services of the target country. Lower costs, quality of services, unavailability of internal facilities, long waiting queues, etc., are the main reasons for people traveling for medical tourism [63,64]. Medical tourism will involve both the private and public sectors [65]. The important point is to correctly and accurately identify the pillars of tourism development in this chain [66]. In other words, by identifying lifestyles, types of luxury, and globalization, and moving toward sustainability and types of consumer behavior, medical tourism can con- tribute to sustainable development [67]. Sustainable medical tourism as a multifaceted phenomenon has several definitions [66,68,69]. The focus of tourists on quality products and services is in fact a requirement to meet their physical, social, and spiritual needs through the development of sustainable tourism and the provision of desirable services [70]. The significant increase in the number of medical tourists in recent years is directly and indirectly determined by environmental indicators on human health and well-being [71]. The results of numerous researches of scientists show that there are two motivations in medical tourists to travel: the first is related to the economic situation, political climate, and Sustainability 2021, 13, 683 9 of 32

hospitality standards, and the second is related to medical service providers in the target country, which includes costs, accreditation standards, and service quality, including pro- fessional qualifications [3]. In fact, the development of sustainable tourism is to strengthen the opportunities ahead while maintaining the needs of tourists [3]. All resources and facilities must be mobilized to maintain cultural interaction, environmental, economic, and social and information sharing needs. In many scientific sources, the subject of sustain- ability refers to: 1—ideal natural resources, 2—respect for the comprehensive cultural and social originality of the host, 3—ensuring positive and sustainable economic performance, 4—providing social and economic benefits for all stakeholders, 5—participation of all stakeholders, 6—satisfaction of tourists [30,72]. In some sources, providing high quality services is the key to sustainable competitive advantage [73]. The need to pay attention to the sustainable development of medical tourism along with the positive economic impact on the host community and surrounding areas as well as the access of millions of people to a variety of affordable medical services can create strong social impacts [3]. Tourists’ experiences of traveling to countries tar- geted for medical tourism can be valuable. Then, creating a chain of cooperation between governments to strengthen the opportunities for medical tourism and introduce differ- ent services to each other can lead to sustainable economic, social, environmental, and cultural development.

2.3. Iranians and Medical Trips Despite the various facilities inside the country, Iranians in some cases prefer to travel to different countries to do the following: - Medical Tourism: This type of trip is done to treat the disease, perform surgery, or check the health of the tourist in the clinics and hospitals of the destination country. The existence of experienced physicians, medical history, medical and supervisory infrastructures, standard hospitals and clinics, complete and up-to-date medical equipment, as well as laws and medical supervision are among the important medical infrastructures of the destination country. - Curative Tourism: Travel to countries with natural healing resources such as hot springs, salt lakes, mud baths, clean environment, and bright sunshine is included in the nature tourism. On this type of trip, skin, respiratory, rheumatology, and muscle patients travel to these areas for medical massage, herbal baths, as well as to recover from treatment and surgery. - : In health tourism, the tourist travels to get rid of the stresses of daily life and seek peace. Usually, these tourists do not have a specific physical illness and are more interested in enjoying the healing nature and avoiding the hustle and bustle of urban life. Health tourists travel for a variety of services, including fitness and exercise, beauty treatments, healthy eating and weight management, relaxation and stress reduction, meditation, yoga, and health-related training.

2.4. Benefits and Reasons for Choosing Health Tourism as a Treatment There are many reasons why Iranians go abroad for medical treatment, the most important of which are: - Disappointment with treatment in their home country, - Lack of access to medical care at an appropriate time and cost, - Insufficient insurance and income to cover the costs of local health services, - High quality medical care in developing countries, - Variety of treatment options, - Desire to receive medical care away from a monotonous and permanent place (escapism), - Lack of waiting list, - Growing popularity for overseas medical services, - Access to the latest technologies, - Existence of oppressive sanctions and access to all kinds of drugs. Sustainability 2021, 13, 683 10 of 32

2.5. Analysis Methods 2.5.1. Analytic Hierarchy Process (AHP) and Analytic Network Process (ANP) Çavmak and Çavmak (2020) identified and prioritized 23 medical tourism barriers in . They divided the barriers into five general categories and prioritized them with an AHP approach. The criteria considered included the following: target brand, social issue, tour holder, target market, tourism product, and communication channels [44]. Lou et al. (2019) presented the risk factors in the sustainable development of healthy cities using the AHP approach. The criteria considered included the following: “safety,” “sustainable ecology,” “vitality and health,” “culture friendly” and “convenience and pros- perity.” The results indicated that safety is selected as the most important criterion [47]. Yıldız and Khan (2019) investigated the aspects that are considered relatively more impor- tant by medical tourists from the Arab region in Turkey. Two indicators of performance and importance were considered to evaluate the proposed criteria with the collected question- naire. The results indicated the appropriate performance of the AHP approach to prioritize options [48]. Rezaeenour et al. (2018) in Iran evaluated the quality of hospital services, with the aim of developing medical tourism, with a combined approach to fuzzy AHP and TODIM [52]. Moreover, TODIM is the Portuguese abbreviation for Interactive and Multi Criteria Decision Making. Roy et al. (2017) in an attractive study evaluated and selected medical tourism sites based on the R-AHP and R-MABAC approach [74]. The acronym MABAC stands for Multi-Attributive Border Approximation Area Comparison. In their study, Görener and Ta¸sçı(2016) evaluated medical tourism strategies based on the SWOT framework with a combined AHP and MOORA approach [75]. The acronym SWOT is based on the following key elements: Strengths, Weaknesses, Opportunities, and Threats, while MOORA framework stands for Multi-Objective Optimization by Ratio Analysis. In a study, Levary (2011) ranked medical tourism destinations by AHP [57]. Bies and Zacharia (2007) addressed the issue of surgery (Outsourcing Surgical Care) in medical tourism using the ANP approach [76].

2.5.2. TOPSIS Arif et al. (2019) investigated medical tourism destination priority in Batu City. They presented the 6AsTD framework and TOPSIS method as a combination concept to rank medical tourism destinations. TOPSIS represents one of the MCDM (Multiple Criteria Decision Making) methods with a large applicability. The acronym TOPSIS stands for Technique for Order Performance by Similarity to Ideal Solution. The 6AsTD method has six criteria that reflect successful medical tourism destinations. The research results indicated the appropriate performance of the proposed combined approach [49]. Rezaee (2019) investigated the location of medical tourism destinations in Charmahal and Bakhtiaree Province. They used GIS model for locating destinations and used the TOPSIS method for ranking them. The results showed that Chelgerd was selected as the best tourist destination [77]. Nilashi et al. (2019) presented factors that influenced medical . They considered environmental, human, and technological factors. The data were collected from hotel managers. They used fuzzy TOPSIS and DEMATEL methods for ranking alternatives. On the other hand, the acronym DEMATEL stands for Decision making trial and evaluation laboratory. Finally, the results showed that technological factors are the most important factors [46].

2.5.3. DEMATEL Farzin et al. (2019) used fuzzy Delphi and fuzzy DEMATEL to predict the demand for medical (Iran) [45]. Modiri et al. (2017) in their research selected medical tourism strategies based on the SWOT framework with a combined approach of fuzzy DEMATEL, fuzzy ANP, and fuzzy VIKOR [78]. The acronym VIKOR is in Serbian language and stands for vlseKriterijumska Optimizacija I Kompromisno Resenje and also represents a multi-criteria decision making (MCDM) method. Taghvaei and Goodarzi (2016) also prioritized medical tourism strategies with a combination of fuzzy DEMATEL, fuzzy ANP Sustainability 2021, 13, 683 11 of 32

and AHP [79]. Chen (2012) used the DEMATEL approach to develop medical [80].

2.5.4. VIKOR Taghizadeh Yazdi and Barazandeh (2016) evaluated and prioritized the barriers to the development of health tourism in Iran with a fuzzy VIKOR approach [81]. Hung et al. (2014) Sustainability 2021, 13, x FOR PEERimproved REVIEW medical screening services with a combined DEMATEL-ANP11 (DANP) of 32 and

VIKOR approach [82].

2.5.5.al. Other (2014) Techniques improved medical screening services with a combined DEMATEL-ANP Abouhashem(DANP) and VIKOR Abadi approach et al. (2018) [82]. evaluated medical tourism strategies in their research study based on the best–worst method (BWM) approach [83]. Although Iran has been very 2.5.5. Other Techniques successful in providing medical services in recent years, there is not a global priority for Abouhashem Abadi et al. (2018) evaluated medical tourism strategies in their medicalresearch tourism. study Therefore, based on the in best this–worst research, method with (BWM) a fuzzy approach approach, [83]. Although we seek Iran to identify the medicalhas been tourism very successful criteria in and providing prioritize medical the most services important in recent countries years, there regarding is not a medical tourismglobal for priority the Iranians. for medical tourism. Therefore, in this research, with a fuzzy approach, we seek to identify the medical tourism criteria and prioritize the most important 3. Materialscountries andregarding Methods medical tourism for the Iranians. The main objective of this research study was to select and rank the medical tourism 3. Materials and Methods destinations for the Iranian people. Questionnaires on the motivation of individuals to The main objective of this research study was to select and rank the medical choose medical tourism destinations were distributed and collected during 2019. According tourism destinations for the Iranian people. Questionnaires on the motivation of to theindividuals population to size, choose which medical was 750tourism people, destinations the sample were size distributed was calculated and collected as 256 people, basedduring on the 2019. Cochran According method. to the population The statistical size, which population was 750 people, included the sample people size who have traveledwas calculated as medical as 256 tourists people, from based Iran on the to Cochran other countries. method. The This statistical statistic population was based on informationincluded frompeople the who Ministry have traveled of Health as medical of Iran tourists from from 2019.The Iran to other analysis countries. was This performed in twostatistic parts. was In based the first on information part, fuzzy from SWARA the Ministry was usedof Health to weigh of Iran the from specified 2019.The criteria and sub-criteria;analysis was performed and in the in secondtwo parts. part, In the the first PROMETHEE part, fuzzy SWARA method was was used used to weigh to prioritize the specified criteria and sub-criteria; and in the second part, the PROMETHEE method eight countries with the highest level of medical tourism, selected based on the indicators was used to prioritize eight countries with the highest level of medical tourism, selected and opinionsbased on theof experts. indicators The and executive opinions of framework experts. The of executive the research framework is presented of the in the followingresearch Figure is presented1. in the following Figure 1.

Figure 1.FigureThe 1. executive The executive framework framework of of the the research. research. Source: Source: Author’s Author’s own own contribution contribution..

There is a limit to the use of the PROMETHEE technique to compensate for the weakness of one criterion or the strength of another. Therefore, an ideal alternative Sustainability 2021, 13, 683 12 of 32

There is a limit to the use of the PROMETHEE technique to compensate for the weakness of one criterion or the strength of another. Therefore, an ideal alternative should obtain the minimum of all criteria. In addition, the PROMETHEE method is easily able to use criteria with different measurement scales (no need to normalize the scale of the criteria) and defines the criteria for the six separate preference functions information. Therefore, in multi-criteria decision-making such as PROMETHEE, which usually has different measurement criteria, there was a strong point for decision-making. The reasons for using SWARA approach were as follows: Firstly, SWARA’s approach is different from other similar methods, such as ANP and AHP. SWARA gives the chance to decision makers to select their priority based on the current situation of alternatives. Secondly, the role of the experts is very important in this approach. At the end, it should be added that SWARA has the advantage of a more logical calculation of weights and relative importance of criteria [84].

3.1. Fuzzy SWARA The use of fuzzy numbers in analysis is due to uncertainty in decisions [85]. The use of fuzzy SWARA is less common in decision-making literature [86]. Some researchers have been working on this in recent years [87,88]. Crisp SWARA, developed by Keršuliene et al. [89], is inadequate to handle uncertainty, so the fuzzy extension of this method was developed. The reason for using the fuzzy SWARA approach was the inherent uncertainty of deciding on medical tourism destinations. Also, due to the qualitative nature of most of the criteria and the ease of collecting the opinions of decision makers, a SWARA fuzzy approach was used. Using a fuzzy approach brings the results closer to the real world. The process of determining the relative weight of the criteria using the SWARA method with the following steps can be shown in detail [90]: We arranged the criteria in descending order. According to the Table2, we determined the relative importance of factor j compared to the previous factor (j-1), which was of higher importance.

Table 2. Fuzzy and linguistic values [91].

Linguistic Scale Response Scale Equally Important (1,1,1) Moderately Less Important (2/3,1,3/2) Less Important (2/5,1/2,2/3) Very Less Important (2/7,1/3,2/5) Much Less Important (2/9,1/4,2/7) Source: Author’s own contribution. ∼ 1. Calculate the value of k j using Equation (1). It should be noted that the fuzzy parameters are shown with the symbol ~.

 ∼  ∼  1j = 1  k j = ∼ (1)  Sj + 1j > 1 

∼ where k j is the value of the coefficient of comparative importance. ∼ 2. Calculate the value of q j using Equation (2):   1j = 1 ∼  ∼  q j = k j−1 (2)  ∼ j > 1   k j  Sustainability 2021, 13, 683 13 of 32

∼ where q j is value of the fuzzy weights of the criteria. 3. Calculate the weight of the criteria using Equation (3), ∼ where n is the number of criteria and Wj is the weight of the criterion j:

∼ ∼ q j W = . (3) j n ∼ ∑ qk k=1

3.2. PROMETHEE The PROMETHEE method uses outranking method relation between alternatives to solve problems that have a finite action and need to be sorted considering different criteria and different units [92,93]. Unlike other ranking methods, which apply the same ranking scale and preference function (PF) in the ranking process, PROMETHEE usually uses different preference functions to define different decision attributes according to their different characteristic [94,95]. The procedure of PROMETHEE is constituted by four steps: Calculating the deviations based on comparison between two alternatives with respect to j the criterion using Equation (4):

dj(a, b) = fj (a) − fj (b) j = 1, 2, . . . , k (4)

where j denotes the jth criterion k stands for the finite number of criteria. dj(a, b) is the difference between the evaluations of two actions (a) and fj(b)) for criterion. Applying the preference function using Equations (5) and (6):  Pj(a, b) = Fj dj(a, b)] j = 1, 2, . . . , k (5)

0 ≤ Pj ≤ 1 j = 1, 2, . . . , k (6)

where Pj(a, b) expresses the preference for alternative a with regard to alternative b on the jth criterion. Calculating a global preference index. The overall multi-criteria preference list π(a, b) is denoted as Equation (7):

k π(a, b) = ∑ WjPj(a, b)j = 1, 2, . . . , k (7) j=1

where wj represents the weight of the criterion j. Calculating the outranking flows. The outgoing flow phi+, which defines the outrank- ing of alternative a (how a dominates all the other alternatives), and the incoming flow phi−, which indicates the outranked character of alternative a (how a is dominated by all the other alternatives), can be represented as follows [96]:

+(a)= ∑ π(x,a) phi x∈A , (8)

−(a)= ∑ π(a,x) phi x∈A (9) where a denotes the alternative set and x represents all alternatives except alternative a. The net flow phi(a), which is defined by Equation (10), expresses the overall preferred degree of alternative a. Higher value of phi(a) means a better performance of alternative a.

phi(a)phi. (10) Sustainability 2021, 13, 683 14 of 32

4. Results and Discussion After conducting the research steps, the specified criteria are presented in Table3. To select these criteria, the opinions of five experts with more than 20 years of experience in the field of medical tourism were used. These experts were among the most experienced surgeons in the country who have been working in the field of medical tourism in various countries for many years. These people were among the most experienced and specialized university people in the field of medical tourism in the country. These experts were selected only to select criteria and the questionnaire was filled by medical tourists. Table3 shows the criteria used to select a medical tourism destination. The options (alternatives) considered by experts were Brazil, Costa Rica, India, Mexico, Panama, Singapore, Taiwan and Malaysia. The reasons were the high incomes and foreign exchange earnings that the medical tourism of these countries had, and many governments are trying to strengthen this industry in their country. The global and local weights of the considered criteria and sub-criteria obtained by fuzzy SWARA approach are shown in Table4: Table5 shows the output results of Visual PROMETHEE software. The official site and the tutorial version of the software can be downloaded from http://www.promethee- + − gaia.net. This table shows the values of Phi (a), Phi(a) and Phi(a) . The value of Phi (a) + − is equal to the difference between the values of Phi(a) and Phi(a) . The GAIA plane is the principal plane obtained by applying a principal components analysis to the set of actions in this space. Moreover, a GAIA plane represents a focal-plane assembly and has a major applicability in space applications. In the GAIA plane, the following relationships hold: 1. The longer the axis of a criterion is, higher the distinguishing power of that criterion will be. 2. The criteria that have similar preferences are shown by almost parallel axes. 3. The criteria that have conflicting preferences are shown in opposite directions. 4. The criteria that do not communicate with each other (in terms of the preference) are perpendicular to each other. 5. The similar actions are shown by points close to each other. 6. Suitable actions on a criterion are shown by points in the direction of the given criteria. Sustainability 2021, 13, 683 15 of 32

Table 3. Identified sustainable criteria for choosing a medical tourism destination.

No Criteria Sustainability Dimension Sub-Criteria Definition Number of doctors and nurses for fast and far from Staff quantity (c1) expectation services Increase the operational capacity of physicians and nurses Staff quality (c2) in serving patients 1 Abilities of skilled staff Social Up-to-date staff (c3) Develop staff information capacity about patients Specialized staff (c4) Use of experienced specialists and trained personnel Familiarity of staff with foreign languages (c5) Familiarity with different dialects and languages Observing international standards (c6) Utilizing the highest standards in providing services Performing various medical and care services with Using experienced professionals to treat tourists (c7) international specialists 2 Applied medical equipment Utilizing the highest equipment and familiar with new Using modern medical equipment and procedures (c8) methods for treating patients Paying attention to the appropriate space to introduce the Describe the different sections for reception and service hospital to tourists (c9) Providing extensive advertising to introduce the hospital to New methods of advertising to introduce medical centers tourists (c10) and medical services Organizing and providing the most effective treatment plan to Use international doctors and introduce their programs Economic the international medical community (c11) 3 Marketing capability Spending on marketing and attracting tourists (c12) Increase advertising costs Use the potential and effective capacity of specialized Hiring specialized staff for planning and advertising (c13) forces to attract tourists Receiving minimum medical expenses from tourists (c14) Receiving minimum medical expenses from tourists Spending the least possible time for hospitalizing tourists (c15) Spending the least possible time for hospitalizing tourists

4 Type of service provided Diversity of medical services (c16) Diversity of medical services Minimizing bureaucracy to accept patients (c17) Minimizing bureaucracy to accept patients Friendly behavior of medical staff toward tourists (c18) Friendly behavior of medical staff toward tourists Sustainability 2021, 13, 683 16 of 32

Table 3. Cont.

No Criteria Sustainability Dimension Sub-Criteria Definition Having a special website to introduce the diversity and A specialized and special website to introduce all kinds of environmental-therapeutic attractions of the destination medical tourism attractions with good and easy access and country (c19) transparent information Application of information and communications Coordinating the patient’s medical information with the 5 Environmental Identify the condition and situation of the patient in the technology hospital of the country of origin to inform about the types of country of origin and check his or her opinion and interest special environmental attractions, taking into account the in having all kinds of facilities in the destination country physical and mental conditions (c20) Source: Author’s own contribution. Sustainability 2021, 13, 683 17 of 32

Table 4. The criteria and sub-criteria obtained by fuzzy SWARA.

Main Criteria Wj Sub-Criteria bj kj qj Wj Local Weight Global Weight c2 (1, 1, 1) (1, 1, 1) (0.360, 0.466, 0.420) 0.415 0.073 c3 (0.4, 0.5, 0.667) (1.4, 1.5, 1.667) (0.714, 0.666, 0.599) (0.257, 0.310, 0.252) 0.274 0.0482 Abilities of skilled staff 0.176 c4 (0.23,1.5,0.465) (1.23, 2.5, 1.465) (0.580, 0.266, 0.408) (0.209, 0.124, 0.171) 0.169 0.0297 c1 (1, 1, 1) (2, 2, 2) (0.29, 0.133, 0.204) (0.104, 0.062, 0.085) 0.084 0.0147 c5 (0.540, 0.650, 0.23) (1.54, 1.65, 1.23) (0.188, 0.08, 0.165) (0.067, 0.037, 0.069) 0.058 0.0102 c7 (1, 1, 1) (1, 1, 1) (0.429, 0.579, 0.456) 0.489 0.1134 c8 (0.53, 1.74, 0.37) (1.53,2.74,1.37) (0.653, 0.364, 0.729) (0.280, 0.210, 0.332) 0.273 0.0633 Applied medical equipment 0.232 c6 (0.444, 0.5, 1.36) (1.444, 1.5, 2.36) (0.452, 0.242, 0.308) (0.193, 0.14, 0.14) 0.159 0.0368 c9 (1, 1, 1) (2, 2, 2) (0.226, 0.121, 0.154) (0.096, 0.070, 0.070) 0.079 0.0183 c11 (1,1,1) (1,1,1) (0.450, 0.496, 0.537) 0.495 0.0534 c12 (0.5, 0.66, 1.12) (1.5, 1.66, 2.12) (0.666, 0.602, 0.471) (0.299, 0.298, 0.252) 0.284 0.0306 Marketing capability 0.108 c13 (1.04, 1.5, 1) (2.04, 2.5, 2) (0.326, 0.24, 0.235) (0.146, 0.119, 0.126) 0.131 0.0141 c10 (0.42, 0.373, 0.5) (1.42, 1.373, 1.5) (0.229, 0.174, 0.156) (0.103, 0.086, 0.083) 0.090 0.0097 c14 (1, 1, 1) (1, 1, 1) (0.459, 0.503, 0.52) 0.495 0.1955 c16 (1, 1, 1) (2, 2, 2) (0.5, 0.5, 0.5) (0.229, 0.251, 0.26) 0.247 0.0975 Type of service provided 0.395 c15 (0.63, 1.2, 1) (1.63, 2, 2) (0.306, 0.25, 0.25) (0.14, 0.125, 0.13) 0.132 0.0521 c17 (0.444, 0.76, 0.1.32) (1.444,1.76,2.32) (0.211, 0.142, 0.107) (0.097, 0.071, 0.055) 0.075 0.0296 c18 (0.333, 0.5, 0.666) (1.333, 1.5, 1.666) (0.158, 0.094, 0.064) (0.072, 0.047, 0.033) 0.051 0.0201 Application of information and c19 (1, 1, 1) (1, 1, 1) (0.666, 0.666, 0.666) 0.666 0.0592 0.089 communications technology c20 (1, 1, 1) (2, 2, 2) (0.5, 0.5, 0.5) (0.333, 0.333, 0.333) 0.334 0.0297 Source: Author’s own contribution. Sustainability 2021, 13, 683 18 of 32

Table 5. Results of PROMETHEE calculation.

Actions Phi Phi+ Phi− India 0.1396 0.5213 0.3818 Malaysia 0.1128 0.4905 0.3778 Panama 0.0976 0.4971 0.3995 Mexico 0.0790 0.4854 0.4064 Singapore 0.0096 0.4566 0.4470 Taiwan −0.0442 0.4188 0.4630 Brazil −0.1747 0.3629 0.5375 Costa Rica −0.2196 0.3405 0.5601 Source: Author’s own contribution.

Table6 shows the global decision matrix obtained by the experts’ opinions.

Table 6. Global decision matrix.

A/C C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 C16 C17 C18 C19 C20 A1 Vb A A A A G A B A G Vg Vg Vg A B G G A Vb Vg A2 Vg A A Vg Vg G A Vg B B A Vg G G G G B B G B A3 G G A G G A A Vb B B Vg Vb A Vg G G Vg B G G A4 B A A A A B G Vb Vg B A A Vg Vb Vb A Vg G G B A5 A G A Vg A G B A Vg Vg G B Vg G B Vg G Vg G Vg A6 G A G G A B B Vg Vb Vg A B Vb A G B A G B Vb A7 A A G A A A A Vg Vb A Vb B Vb G Vg B B A A Vg A8 G A G B A A A Vb Vg A B G Vb G Vb B A B B Vb Source: Author’s own contribution. Note: Vb: Very bad, B: Bad, A: Average, G: Good, Vg: Very good, A1: Panama, A2: Malaysia, A3: Mexico, A4: Singapore, A5: India, A6: Taiwan, A7: Brazil, A8: Costa Rica.

Table7 shows the numerical values of the linguistic terms.

Table 7. Numerical values of the linguistic terms.

Linguistic Term Value Vb 9 B 7 A 5 G 3 Vg 1 Source: Author’s own contribution.

Table8 presents the type of optimization of the sub-criteria and the preference func- tions as follows:

Table 8. Type of optimization of the sub-criteria and the preference functions.

A/C c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20 Type Max Max Max Max Max Max Max Max Max Max Max Max Max Min Min Max Min Max Max Max PF Lin U U U U U U U U U U U U Us Us U U U U U Source: Author’s own contribution. U: Usual, Us: U-shape, Vs: V-shape, L: Level, Lin: Linear, G: Gaussian. Sustainability 2021, 13, x FOR PEER REVIEW 17 of 32

Table 7. Numerical values of the linguistic terms.

Linguistic Term Value Vb 9 B 7 A 5 G 3 Vg 1 Source: Author’s own contribution.

Table 8 presents the type of optimization of the sub-criteria and the preference functions as follows:

Table 8. Type of optimization of the sub-criteria and the preference functions.

A/C c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20 Typ Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Mi Mi Ma Mi Ma Ma Ma Sustainability 2021, 13, 683 e x x x x x x x x x x x x x n n x n x x x 19 of 32 PF Lin U U U U U U U U U U U U Us Us U U U U U Source: Author’s own contribution. U: Usual, Us: U-shape, Vs: V-shape, L: Level, Lin: Linear, G: Gaussian. According to Table4, the GAIA plane is shown in Figure2. This figure is the output of the VisualAccording PROMETHEE to Table 4, the software. GAIA plane Due is to shown the multidimensionality in Figure 2. This figure of is thethe GAIAoutput plane, theof left-side the Visual plane PROMETHEE shows the software. U–V dimension, Due to the multidimensionality and the right-side of plane the GAIA shows plane, the U–W dimensionthe left-side (Figure plane2 ).shows The redthe axisU–V isdimension, called the and decision the right brain-side and plane shows shows the the preference U–W of thedimension decision makers.(Figure 2). As The can red be axis seen is in called the left-sidethe decision plane, brain India and is shows closer the to preference the criteria than of the decision makers. As can be seen in the left-side plane, India is closer to the criteria other countries, and Costa Rica and Brazil are the farthest. According to this plane, criteria than other countries, and Costa Rica and Brazil are the farthest. According to this plane, c8 and c15 are in the same direction and also, criteria c7 and c9 are in the same direction. criteria c8 and c15 are in the same direction and also, criteria c7 and c9 are in the same Thisdirection. indicates This that indicates these criteria that these have criteria similar have objectives. similar objectives. The proximity The proximity of c6, c18 of and c6, c10 to Indiac18 indicatesand c10 to thatIndia it indicates performed that well it performed in terms well of these in terms criteria. of these criteria.

Sustainability 2021, 13, x FOR PEER REVIEW 18 of 32

FigureFigure 2. GAIA2. GAIA plane plane analysis. analysis. Source: Author’s Author’s own own contribution. contribution.

TheThe results results of of the the right-sideright-side plane plane indicate indicate that that the the decision decision brain brain is inclined is inclined toward toward India,India, and and according according to this to this plane, plane India, India was was selected selected as option as option 1. Taiwan 1. Taiwan also performed also wellperformed in terms well of c8 in and terms c4, whileof c8 and it performed c4, while it poorly performed in terms poorly of c3in andterms c7. of The c3 and gap c7. between The gap between India and Costa Rica in this plane shows the difference between the India and Costa Rica in this plane shows the difference between the criteria of these two criteria of these two countries and also their ranking. countriesTable and 9 shows also their the ranking ranking. of medical tourism destinations. This table is the output of Tablethe Visual9 shows PROMETHEE the ranking software of medical and the tourism PROMETHEE destinations. V method. This As table can isbe the seen output in of thethe Visual PROMETHEE PROMETHEE V results, software Costa and Rica the was PROMETHEE the last option V method. for a medical As can be touris seenm in the PROMETHEEdestination and V results,Brazil was Costa the seventh Rica was option. the last Taiwan option and for Singapore a medical also tourism ranked destinationsixth and fifth, respectively. So the global ranking was India, Malaysia, Panama, Mexico, Singapore, Taiwan, Brazil, and Costa Rica, respectively. The optimal results of the objective function of the PROMETHEE V approach were 0.6453 (0.2522 + 0.2982 + 0.0636 + 0.0312). From the PROMETHEE 2 method, which is a complete ranking, we got a complete summary of the options ranking. But PROMETHEE V also includes restrictions on criteria; for example, if we have a measure called cost or budget, we can create a limit on this criterion.

Table 9. PROMETHEE V global ranking.

Actions Net Flow Optimal Malaysia 0.2522 yes Taiwan −0.0726 no Brazil −0.3157 no Mexico −0.0619 no Panama 0.2982 yes India 0.0636 yes Costa Rica −0.1951 no Singapore 0.0312 yes Total 0.6453 Source: Author’s own contribution.

Figure 3 shows the GAIA web plane. This figure is the output of the Visual PROMETHEE software. This plane shows the importance and quality of a criterion Sustainability 2021, 13, 683 20 of 32

and Brazil was the seventh option. Taiwan and Singapore also ranked sixth and fifth, respectively. So the global ranking was India, Malaysia, Panama, Mexico, Singapore, Taiwan, Brazil, and Costa Rica, respectively. The optimal results of the objective function of the PROMETHEE V approach were 0.6453 (0.2522 + 0.2982 + 0.0636 + 0.0312).

Table 9. PROMETHEE V global ranking.

Actions Net Flow Optimal Malaysia 0.2522 yes Taiwan −0.0726 no Brazil −0.3157 no Mexico −0.0619 no Panama 0.2982 yes India 0.0636 yes Costa Rica −0.1951 no Singapore 0.0312 yes Total 0.6453 Source: Author’s own contribution.

From the PROMETHEE 2 method, which is a complete ranking, we got a complete summary of the options ranking. But PROMETHEE V also includes restrictions on cri- teria; for example, if we have a measure called cost or budget, we can create a limit on Sustainability 2021, 13, x FOR PEER REVIEWthis criterion. 19 of 32

Figure3 shows the GAIA web plane. This figure is the output of the Visual PROMETHEE software. This plane shows the importance and quality of a criterion based on the desired option. The left-side plane shows the criteria for India. According to this plane, India based on the desired option. The left-side plane shows the criteria for India. According performed well in terms of “paying attention to the appropriate space to introduce the to this plane, India performed well in terms of “paying attention to the appropriate hospital to tourists (c9)” and “providing extensive advertising to introduce the hospital to space to introduce the hospital to tourists (c9)” and “providing extensive advertising to tourists (c10).” In addition, this country was able to satisfy tourists in terms of “friendly introduce the hospital to tourists (c10).” In addition, this country was able to satisfy behavior of medical staff towards tourists (c18),” ”having a specific website for hospital tourists in terms of “friendly behavior of medical staff towards tourists (c18),” ”having a introduction (c19),” and “specialized staff (c4).” specific website for hospital introduction (c19),” and “specialized staff (c4).”

Figure 3. GAIA web. Source: Author’s Author’s own own contribution. contribution.

The right-side plane shows the quality of the criteria for Malaysia. This country performed well in terms of “staff quantity (c1),” “familiarity of staff with foreign languages (c5),” “using modern medical equipment and procedures (c8),” and “spending on marketing and attracting tourists (c12).” This country was weak in terms of “providing extensive advertising to introduce the hospital to tourists (c10)” and “friendly behavior of medical staff towards tourists (c18)”. Figure 4 shows the walking weights chart. This figure is the output of the Visual PROMETHEE software. This figure shows the sensitivity analysis of medical tourism destinations in terms of the criteria considered. The right-side chart shows the sensitivity analysis based on the “staff quantity (c1).” As can be seen by the increase in the weight of this criterion up to 50% and keeping the weights of the other criteria constant, Malaysia was selected as the top medical tourism destination, followed by Mexico in second rank. It indicates that the two countries were in a good condition in terms of staff quantity. Costa Rica, Taiwan, India, Singapore, Panama, and Brazil ranked third to eighth, respectively. According to this chart, Brazil was weaker than other countries in terms of staff quantity and needs to improve. Sustainability 2021, 13, 683 21 of 32

The right-side plane shows the quality of the criteria for Malaysia. This country performed well in terms of “staff quantity (c1),” “familiarity of staff with foreign languages (c5),” “using modern medical equipment and procedures (c8),” and “spending on market- ing and attracting tourists (c12).” This country was weak in terms of “providing extensive advertising to introduce the hospital to tourists (c10)” and “friendly behavior of medical staff towards tourists (c18)”. Figure4 shows the walking weights chart. This figure is the output of the Visual PROMETHEE software. This figure shows the sensitivity analysis of medical tourism destinations in terms of the criteria considered. The right-side chart shows the sensitivity analysis based on the “staff quantity (c1).” As can be seen by the increase in the weight of this criterion up to 50% and keeping the weights of the other criteria constant, Malaysia was selected as the top medical tourism destination, followed by Mexico in second rank. It indicates that the two countries were in a good condition in terms of staff quantity. Costa Rica, Taiwan, India, Singapore, Panama, and Brazil ranked third to eighth, respectively. Sustainability 2021, 13, x FOR PEER REVIEWAccording to this chart, Brazil was weaker than other countries in terms of staff quantity20 of 32

and needs to improve.

Figure 4. Walking weights. Source: Author’s own own contribution. contribution.

TheThe left-sideleft-side chart chart shows shows the the sensitivity sensitivity analysis analysis of medical of medical tourism tourism destinations destinations based basedon the on “up-to-date the “up-to staff-date (c3).” staff With(c3).” aWith 50% a increase 50% increase in the in weight the weight of this of criterion, this criterion, Costa CostaRica was Rica chosen was chosen as the as best the country. best country. It indicates It indicates that thisthat countrythis country performed performed very very well wellin this in regard.this regard. Taiwan, Taiwan, Panama, Panama, Singapore, Singapore, and Mexicoand Mexico were were also rankedalso ranked second second to fifth. to fifth.Countries Countries thatperformed that performed poorly poorly in this in regard this regard include include Brazil, Brazil, India, India, and Malaysia, and Malaysia, which whichranked ranked fifth to eighth. fifth to These eighth. countries These countriesneed to make need efforts to make to improve efforts this to improvecriterion. this criterTheion. following Figure5 shows the PROMETHEE rainbow chart. The criteria with positiveThe net following Phi values Figure are at 5 theshows top theof the PROMETHEE chart and the rainbow criteria with chart. negative The criteria net Phi with are positivedisplayed net at Phi the values bottom are of theat the chart. top Indiaof the had chart the and best the performance criteria with compared negative tonet other Phi arecountries displayed in terms at the of bottom criteria of c9, the c13, chart. c18, c16,India while had theit did best not performance perform well compared in terms to of othercriteria countries c14, c12, c15in terms and c5. of Malaysia criteria c9, had c13, the bestc18, performance c16, while it in did terms not of perform criterion well c8 and in termsthe worst of criteria performance c14, c12, in terms c15 and of criterion c5. Malaysia c17. In had Panama, the best c13 performance was the best and in terms c19 was of criterionthe worst c8 criterion. and the worst performance in terms of criterion c17. In Panama, c13 was the best and c19 was the worst criterion. Sustainability 2021, 13, 683 22 of 32 Sustainability 2021, 13, x FOR PEER REVIEW 21 of 32

Figure 5. PROMETHEE rainbow. Source: Author’s own contribution Figure 5. PROMETHEE rainbow. Source: Author’s own contribution

MexicoMexico and Singapore Singapore had had the the best best performance performance in in terms terms of criteria of criteria c11 c11and and c13, c13,and andthe worstthe worst performance performance in terms in terms of criteria of criteria c12 andc12 and c14, c14, respectively. respectively. Taiwan Taiwan had thehad best the bestperformance performance in terms in terms of criterion of criterion c8 and c8 and the worstthe worst performance performance in terms in terms of criterion of criterion c13. c13.Brazil Brazil performed performed well well only only in terms in terms of criteria of criteria c15, c8,c15, c20, c8, c14,c20, c6,c14, and c6, c19.and c19. In the In end,the end,Costa Costa Rica had Rica the had best the performance best performance in terms of in criterion terms c9of and criterion the worst c9 andperformance the worst in performanceterms of criterion in terms c13. of criterion c13. InIn 2019, 2019, 13,232 13,232 trips trips were were made made from from Iran Iran with with the the intention intention of of medical medical tourism tourism.. Among the tripstrips mademade were were 4398 4398 trips trips to to India. India. There There were were also also 3425 3425 trips trips to Malaysia to Malaysia and and2178 2178 trips trips to Panama. to Panama. The shares The shares of Mexico, of Mexico, Singapore, Singapore, and Taiwan and Taiwan for medical for medicaltourism tourismwere 1011, were 938, 1011, and 755938, trips, and respectively.755 trips, respectively. There were There also 417 were trips also to Brazil417 trips and to 110 Brazil trips andto Costa 110 trips Rica to [97 Costa,98]. AccordingRica [97,98] to. According the statistics to andthe theirstatistics comparison and their with comparison the results with of thethis study, results the of accuracy this study, of ranking the accuracy tourism destinations of ranking from tourism the perspective destinations of the from Iranian the perspectivepeople was confirmed. of the Iranian The peopleresults of was the confirmed. real statistics The also results showed of that the realIndia statistics was selected also showedas the most that popular India was tourist selected destination as the most by Iranians. popular tourist destination by Iranians. InIn order to to verify verify the the model, model, the the proposed proposed model model was was compared compared with with the fuzzy the fuzzy AHP AHPand fuzzy and fuzzy VIKOR VIKOR approaches. approaches. TableTable 10 10 shows shows the the results results of comparing of comparing the ranking the of ranking medical of tourism medical destinations tourism destinationswith different with approaches. different Comparingapproaches. the Comparing results of thethe proposedresults of approachthe proposed with approach the fuzzy withAHP the approach fuzzy shows AHP approachthe difference shows between the difference the 5th and between 6th (Taiwan the 5th and and Singapore) 6th (Taiwan ranks. andComparing Singapore) the resultsranks. Comparing of the proposed the results approach of the with proposed the fuzzy approach VIKOR approach with the showsfuzzy VIKORthe difference approach between shows the the 3rd difference and 4th (Mexicobetween andthe Panama)3rd and 4th ranks. (Mexico It should and Panama) be noted ranks.that the It weightsshould be of thenoted criteria that the in VIKOR weights were of the obtained criteria from in VIKOR fuzzy were SWARA. obtained Due tofrom the fuzzycloseness SWARA. of the rankingDue to the ofthe closeness fuzzy AHP of the and ranking fuzzy VIKORof the fuzzy approaches AHP and with fuzzy the proposed VIKOR approachesapproach, the with accuracy the proposed of the proposed approach, model the was accuracy proved of(Appendix the proposA anded ?? model). was proved (Appendix A and Appendix B).

Table 10. Verification of the results. Sustainability 2021, 13, 683 23 of 32

Sustainability 2021, 13, x FOR PEER REVIEW 22 of 32

Table 10. Verification of the results.

FUZZY FUZZY Rank Proposed Approach FUZZY AHP FUZZY VIKOR Rank Proposed Approach Rank 1 IndiaAHP IndiaVIKOR India Rank 1 India Rank 2 MalaysiaIndia MalaysiaIndia Malaysia Rank 2 Malaysia Malaysia Malaysia Rank 3 Panama Panama Mexico Rank 3 Panama Panama Mexico Rank 4 Mexico Mexico Panama Rank 4 Mexico Mexico Panama Rank 5 Singapore Rank 5 SingaporeTaiwan TaiwanTaiwan Taiwan Rank 6 Taiwan Rank 6 TaiwanSingapore SingaporeSingapore Singapore Rank 7 Brazil Rank 7 BrazilBrazil BrazilBrazil Brazil Rank 8 Costa Rica Rank 8 CostaCosta Rica Rica Costa RicaCosta Rica Costa Rica Source: Author’sAuthor’s own own contribution. contribution.

Figure 6 also showsFigure the6 also weight shows comparisons the weight comparisonsof the criteria ofin thethe criteriafuzzy SWARA in the fuzzy and SWARA and fuzzy AHP methods:fuzzy AHP methods:

0.25

0.2

0.15

fuzz 0.1 y swa ra 0.05

0 c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20

Figure 6.FigureComparison 6. Comparison of criteria of criteria weights weights in fuzzy in AHP fuzzy and AHP fuzzy and SWARA. fuzzy SWARA. Source: Source: Author’s Author’s own contribution. own contribution. For comparing the results with the previous one obtained in the literature, Levary et al. [57] For comparingwas selected. the results The with results the ofprevious Levary one et al.obtained [57] also in provedthe literature, the results Levary of our research. et al. [57] wasLevary selected. et al. The [57 results] also selectedof Levary India et al. as [57] the also first proved destination. the results Therefore, of our comparing the research. Levaryresults et of al. other [57] researchesalso selected in the India literature as the review first also destination. proved the Therefore, results of this research. comparing the resultsFigure of 7other shows researches the results in the of theliterature criteria review sensitivity also proved analysis. the For results this purpose, the of this research.values of the criteria weights were changed and changes in the alternative were observed. The horizontal axis shows the criteria and the vertical axis shows the percentage of changes Figure 7 shows the results of the criteria sensitivity analysis. For this purpose, the in the criteria weights. The blue lines indicate the upper limit and the red lines the lower values of the criteria weights were changed and changes in the alternative were limit. As can be seen from the figure, for example, the upper limit of the first criterion observed. The horizontal axis shows the criteria and the vertical axis shows the change for that alternative ranking remains constant at 16% and the lower limit is 10%. percentage of changes in the criteria weights. The blue lines indicate the upper limit and the red lines the lower limit. As can be seen from the figure, for example, the upper limit of the first criterion change for that alternative ranking remains constant at 16% and the lower limit is 10%. Sustainability 2021, Sustainability13, x FOR PEER2021 REVIEW, 13, 683 23 of 32 24 of 32

20 18 16 14 12 10 8 Upper limit

% Change % Lower limit 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Criteria

Figure 7. The sensitivity of changes in the criteria. Source: Author’s own contribution.

Figure 7. The sensitivity of changes in the criteria. Source: Author’s own contribution. 5. Conclusions 5. Conclusions Health tourism represents one of the fastest growing segments in the tourism industry. Tourism as well as medical tourism can be sustainable if developed and managed, consider- Health tourism represents one of the fastest growing segments in the tourism ing both tourists and communities. This can be achieved through community engagement, industry. Tourism as well as medical tourism can be sustainable if developed and congestion management, reduction of seasonality, careful planning that respects the limits managed, considering both tourists and communities. This can be achieved through of capacity and the specificities of each destination, and product diversification. community engagement, congestion management, reduction of seasonality, careful In this study, using a combined fuzzy SWARA-PROMETHEE approach, famous coun- planning that respects the limits of capacity and the specificities of each destination, and tries in terms of medical tourism were ranked from the viewpoint of the Iranian people. product diversification. Therefore, five main criteria, including abilities of skilled staff, applied medical equipment, In this study,marketing using capability, a combined type fuzzy of services SWARA provided,-PROMETHEE and application approach, of information famous and commu- countries in termsnications of medical technology tourism along were with ranked 20 sub-criteria, from the were viewpoint extracted. of the The Iranian weights of the criteria people. Therefore,were five determined main criteria, using including the fuzzy abilities SWARA of approach. skilled staff, After applied determining medical the weights of the equipment, marketingcriteria, the capability, medical tourism type of destinations services wereprovided, ranked and using application the PROMETHEE of approach. information andIdentifying communications criteria technology related to sustainability along with 20 in sub the- subjectcriteria, of were medical extracted. tourism destinations The weights ofand the prioritizing criteria were medical determined tourism using destinations the fuzzy using SWARA these approach. criteria are After the contributions of determining thethis weights paper. of The the results criteria, showed the medical that India tourism (Phi = destinations 0.1396), Malaysia were (Phi ranked = 0.1128), Panama using the PROMETHEE(Phi = 0.0976), approach. Mexico Identifying (Phi = 0.0790), criteria Singapore related (Phi to sustainability = 0.0096), Taiwan in the (Phi = −0.0442), subject of medicalBrazil tourism (Phi = − destinations0.1747), and and Costa prioritizing Rica (Phi = medical−0.2196) tourism were the destinations medical tourism priorities using these criteriafor Iranians, are the respectively. contributions The of weightsthis paper. of criteria The results for “Abilities showed of that skilled India staff,” “applied (Phi = 0.1396), medical Malaysia equipment,” (Phi = 0.1128), “marketing Panama capability,” (Phi = 0.0976), “type Mexicoof service (Phi provided,” = 0.0790), and “application Singapore (Phi of= information0.0096), Taiwan and (Phi communications = −0.0442), Brazil technology” (Phi = −0.1747), were 0.176, and 0.232, Costa 0.108, Rica 0.395, and 0.089, (Phi = −0.2196)respectively. were the Themedical results tourism of the sensitivity priorities analysis for Iranians, showed respectively. that Malaysia The and Mexico were weights of criteriain good for condition “Abilities in terms of skilled of staff staff,” quantity. “applied Also, medical Brazil performed equipment,” poorly in terms of “marketing capaquantitybility,” staff“type compared of service to provided,” other countries and “application and needs toof improve.information In termsand of up-to-date communicationsstaff, technology” Costa Rica were had 0.176, the best 0.232, performance 0.108, 0.395, and and Malaysia 0.089, hadrespectively. the worst The performance. Sus- results of the tainability sensitivity is analysis a concept showed that has that gained Malaysia increasing and popularityMexico were among in good consumers around condition in termsthe worldof staff [ 99quantity.], and its Also, implications Brazil performed for medical poorly tourism in terms are growing.of quantity To examine the staff comparedverification to other countries of the proposed and needs approach, to improve. the results In terms were compared of up-to-date with staff, the fuzzy AHP and Costa Rica hadfuzzy the VIKOR best performance approaches. andComparing Malaysia the had results the of worst the proposed performance. approach with fuzzy Sustainability isVIKOR a concept approach that showed has gained the difference increasing between popularity the 3th among and 4thconsumers (Mexico and Panama) around the worldranks. [99], Also and comparingits implications the resultsfor medical of the tourism proposed areapproach growing. withTo examine fuzzy AHP approach the verificationshowed of the proposedthe difference approach, between the the results 5th and were 6th (Taiwan compared and with Singapore) the fuzzy ranks. Due to the AHP and fuzzycloseness VIKOR ofapproaches. the ranking Comparing of the fuzzy the AHP results and fuzzy of the VIKOR proposed approaches approach with the proposed with fuzzy VIKORapproach, approach the accuracy showed of the the difference proposed between model was the proved. 3th and 4th (Mexico Sustainability 2021, 13, 683 25 of 32

Some empirical studies [100] revealed that the level of customer satisfaction is directly correlated with their loyalty to the hospital, which is a prerequisite for the progress of the health tourism market. According to certain researchers [101], interest in the preservation of health and quality of life, which includes rest and recuperation, represents the major tourist motivation. According to [102] the category of consumers in the health care system includes the following two main subcategories: external customers, which includes patients, family members of patients, and potential customers, and internal customers, which includes employees and their employers. For instance, Malaysia is perceived as a hub of medical tourism in Southeast Asia, while the health care travel industry is a private- sector-driven [103]. The 1970s established certain Asian countries—Thailand, India and Singapore—as the most popular medical tourism destinations [104]. According to Spulbar et al. (2019), a sustainable development-based approach has significant implications for low and middle-income countries (emerging), considering their main characteristic features such as: demographic dynamics, high degree of , poor quality education, migration, environmental degradation, social inequality, high levels of urbanization, health system deficiencies, rapid technological change, and unsustain- able economic growth [105]. Mehdiabadi et al. (2020) argued that considering current challenges, the global economy is very dynamic and constantly changing, so innovation and technological development represent essential aspects in regards to a sustainable perspective [106]. The results of this study can help countries to strengthen their weaknesses. Also, iden- tifying sustainable criteria for medical tourism destinations and prioritizing destinations can help patients to choose destinations tailored to their needs. Sustainable criteria cover all economic, social, and environmental dimensions. Therefore, identifying and prioritizing criteria can help tourism destinations, for example, European or American countries, to strengthen strengths and reduce their negative criteria. This study, like other studies, has some limitations. One of the limitations of this research paper is the lack of access to more extensive statistical databases. Also, due to the qualitative nature of most of the criteria, including them in the questionnaire and converting them into quantitative criteria was another limitation of this research. Other limitations include the use of fuzzy data and their conversion to Crisp data. Finally, this study is limited to Iranians’ views on medical tourism destinations. Despite the fact that it is a topic of interest, existing literature does not contain many research studies on the linkage between health care aspects and tourism, especially in the current context of the Covid-19 pandemic. The following are recommended for future studies: 1. Prioritizing medical tourism destinations based on the viewpoints of the people living in other countries, such as India, , etc.; 2. Investigating the effect of different countries’ policies on their medical tourism, for example, the policies adopted by countries regarding the COVID-19 outbreak; 3. Considering other criteria in addition to sustainability, such as resiliency, etc.; 4. Considering other uncertainty approaches, such as fuzzy type 2, stochastic, and scenario; 5. Predicting the demand for medical tourism in countries using sustainable criteria; 6. Prioritization of medical tourism destinations with regard to the occurrence of crises such as the COVID-19 outbreak.

Author Contributions: All authors contributed equally to this research work. All authors discussed the results and contributed to the final manuscript. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Conflicts of Interest: The authors declare no conflict of interest. Sustainability 2021, 13, 683 26 of 32 Sustainability 2021, 13, x FOR PEER REVIEW 26 of 32

Appendix A Appendix A FUZZY AHP: In This Article, the Kutlu Gündo˘gduand Kahraman (2019) Framework Was Used to Introduce and Apply the Fuzzy AHP Method [107] According to the Following FUZZY AHP: In This Article, the Kutlu Gündoğdu and Kahraman (2019) Framework Was Used to Introduce and Apply the Table Captions: Fuzzy AHP Method [107] According to the Following Table Captions:

Initial Comparison Matrices

Left Criteria Is Greater Right Criteria Is Greater

AMI VHI HI SMI EI SLI LI VLI ALI A 1 B A 1 C A 1 D A 1 E A 1 F A 1 G A 1 H B 1 C B 1 D B 1 E B 1 F B 1 G B 1 H C 1 D C 1 E C 1 F C 1 G C 1 H D 1 E D 1 F D 1 G D 1 H E 1 F E 1 G E 1 H F 1 G F 1 H G 1 H

FigureFigure A1. A1. InitialInitial Comparison Comparison Matrices. Matrices. Source: Source: Author’s Author’s own own contribution.contribution. SustainabilitySustainability 20212021,, 1313,, 683x FOR PEER REVIEW 27 of 32 27 of 32

A B C D E F G H A 0.500 0.400 0.400 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 B 0.400 0.500 0.400 0.500 0.400 0.400 0.600 0.400 0.300 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 C 0.400 0.600 0.300 0.400 0.600 0.300 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 D 0.300 0.700 0.200 0.400 0.600 0.300 0.400 0.600 0.300 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.700 0.300 0.200 0.800 0.200 0.100 E 0.200 0.800 0.100 0.300 0.700 0.200 0.300 0.700 0.200 0.400 0.600 0.300 0.500 0.400 0.400 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 F 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.300 0.700 0.200 0.200 0.800 0.100 0.500 0.400 0.400 0.800 0.200 0.100 0.800 0.200 0.100 G 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.300 0.700 0.200 0.200 0.800 0.100 0.200 0.800 0.100 0.500 0.400 0.400 0.800 0.200 0.100 H 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.500 0.400 0.400

Crisp Spherical Fuzzy Weights Crisp Weights Weights 0.717 0.273 0.218 0.162 0.162 0.686 0.306 0.240 0.153 0.153 0.673 0.329 0.226 0.151 0.151 0.598 0.405 0.255 0.132 0.132 0.612 0.407 0.202 0.138 0.138 0.526 0.510 0.184 0.118 0.118 0.427 0.607 0.191 0.093 0.093 0.263 0.734 0.189 0.053 0.053

Consistency Ratio (CR) 0.2333 Compare with 0.1; It should be less than 0.1

FigureFigure A2. Integrated A2. Integrated Spherical Spherical Fuzzy FuzzyComparison Comparison Matrix. Matrix. Source: Source: Author’s Author’s own contribution. own contribution.

Appendix B Appendix B FUZZY VIKOR: In this article,FUZZY the Chang VIKOR (2014): In framework this article, was the used Chang to introduce(2014) framework and apply was the used fuzzy to VIKOR introduce method and [apply108] according the fuzzy to VIKOR the following method table [108 captions:] according to the following table captions: Sustainability 2021, 13, 683 28 of 32 Sustainability 2021, 13, x FOR PEER REVIEW 28 of 32 Sustainability 2021, 13, x FOR PEER REVIEW 28 of 32

W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 0.36 0.466W1 0.42 0.257 0.31W2 0.252 0.209 0.124W3 0.171 0.104 0.062W4 0.085 0.067 0.037W5 0.069 0.429 0.579W6 0.456 0.28 0.21W7 0.332 0.193 0.014W8 0.014 0.096 0.07W9 0.07 0.45 0.496W10 0.537 0.299 0.298W11 0.252 0.146 0.119W12 0.126 0.103 0.086W13 0.083 0.459 0.125W14 0.13 0.229 0.071W15 0.26 0.14 0.125W16 0.13 0.097 0.071W17 0.055 0.072 0.047W18 0.033 0.666 0.666W19 0.666 0.333 0.333W20 0.333 0.36 0.466X1 0.42 0.257 0.31X2 0.252 0.209 0.124X3 0.171 0.104 0.062X4 0.085 0.067 0.037X5 0.069 0.429 0.579X6 0.456 0.28 0.21X7 0.332 0.193 0.014X8 0.014 0.096 0.07X9 0.07 0.45 0.496X10 0.537 0.299 0.298X11 0.252 0.146 0.119X12 0.126 0.103 0.086X13 0.083 0.459 0.125X14 0.13 0.229 0.071X15 0.26 0.14 0.125X16 0.13 0.097 0.071X17 0.055 0.072 0.047X18 0.033 0.666 0.666X19 0.666 0.333 0.333X20 0.333 A 15.4000 19.0000X1 22.6000 32.4000 42.0000X2 51.6000 5.0000 8.6000X3 12.2000 9.0000 12.7000X4 16.4000 32.4000 42.0000X5 51.6000 20.8000 24.4000X6 28.0000 26.6000 32.2000X7 37.8000 25.8000 31.1000X8 36.4000 32.4000 42.0000X9 51.6000 23.6000 28.1000X10 32.6000 20.8000 24.4000X11 28.0000 23.0000 27.0000X12 31.0000 29.0000 36.6000X13 44.2000 16.8000 21.8000X14 26.8000 25.8000 32.4000X15 39.0000 26.6000 32.8000X16 39.0000 26.8000 33.6000X17 40.4000 27.0000 33.1000X18 39.2000 32.4000 42.0000X19 51.6000 29.8000 38.8000X20 47.8000 AB 15.40006.2000 19.00009.8000 22.600013.4000 32.400021.6000 42.000028.0000 51.600034.4000 16.60005.0000 20.20008.6000 12.200023.8000 15.80009.0000 12.700019.4000 16.400023.0000 32.400027.0000 42.000035.0000 51.600043.0000 20.800023.0000 24.400028.1000 28.000033.2000 26.600019.4000 32.200023.0000 37.800026.6000 25.800015.6000 31.100018.7000 36.400021.8000 32.400027.0000 42.000035.0000 51.600043.0000 23.600022.8000 28.100027.0000 32.600031.2000 20.800020.6000 24.400024.5000 28.000028.4000 23.000012.2000 27.000014.2000 31.000016.2000 29.000025.8000 36.600031.8000 44.200037.8000 16.800014.6000 21.800017.4000 26.800020.2000 25.800014.6000 32.400017.3000 39.000020.0000 26.600019.8000 32.800025.1000 39.000030.4000 26.800027.0000 33.600035.1000 40.400043.2000 27.000024.2000 33.100029.3000 39.200034.4000 32.400027.0000 42.000035.0000 51.600043.0000 29.800026.6000 38.800034.1000 47.800041.6000 BC 6.20009.8000 13.50009.8000 13.400017.2000 21.600030.0000 28.000038.4000 34.400046.8000 16.600010.0000 20.200013.8000 23.800017.6000 15.800010.4000 19.400014.1000 23.000017.8000 27.000017.6000 35.000023.3000 43.000029.0000 23.000024.2000 28.100028.6000 33.200033.0000 19.400018.6000 23.000022.1000 26.600025.6000 15.600027.8000 18.700034.5000 21.800041.2000 27.000021.6000 35.000028.0000 43.000034.4000 22.800019.0000 27.000022.4000 31.200025.8000 20.600014.8000 24.500017.8000 28.400020.8000 12.200017.2000 14.200020.4000 16.200023.6000 25.800024.2000 31.800028.9000 37.800033.6000 14.600018.0000 17.400025.1000 20.200032.2000 14.600017.6000 17.300021.4000 20.000025.2000 19.800015.8000 25.100018.7000 30.400021.6000 27.000012.8000 35.100016.6000 43.200020.4000 24.200020.0000 29.300026.2000 34.400032.4000 27.000021.6000 35.000028.0000 43.000034.4000 26.600019.0000 34.100024.8000 41.600030.6000 CD 9.80005.2000 13.50008.9000 17.200012.6000 30.000027.0000 38.400035.0000 46.800043.0000 10.000017.2000 13.800020.8000 17.600024.4000 10.400019.0000 14.100022.4000 17.800025.8000 17.60000 23.30000 29.00000 24.200015.0000 28.600018.3000 33.000021.6000 18.600017.8000 22.100021.7000 25.6000 27.800019.2000 34.500022.9000 41.200026.6000 21.600016.2000 28.000021.0000 34.400025.8000 19.000021.4000 22.400025.6000 25.800029.8000 14.800024.4000 17.800029.1000 20.800033.8000 17.200017.0000 20.400020.7000 23.600024.4000 24.200017.0000 28.900020.3000 33.600023.6000 18.0000 25.100021.2000 32.200024.4000 17.600026.4000 21.400032.1000 25.200037.8000 15.800020.8000 18.700024.6000 21.600028.4000 12.800018.0000 16.600021.9000 20.400025.8000 20.000016.2000 26.200021.0000 32.400025.8000 21.600016.2000 28.000021.0000 34.400025.8000 19.000014.2000 24.800018.3000 30.600022.4000 DE 14.80005.2000 18.60008.9000 12.600022.4000 27.00007.8000 35.00009.9000 43.000012.0000 17.20006.2000 20.800010.1000 24.400014.0000 19.00005.4000 22.40008.9000 25.800012.4000 16.20000 21.00000 25.80000 15.000023.6000 18.300028.1000 21.600032.6000 17.800013.0000 21.700016.8000 25.600020.6000 19.200020.8000 22.900024.6000 26.600028.4000 16.200010.8000 21.000014.0000 25.800017.2000 21.400026.2000 25.600031.3000 29.800036.4000 24.400015.4000 29.100018.7000 33.800022.0000 17.000016.2000 20.700019.4000 24.400022.6000 17.000011.4000 20.300013.6000 23.600015.8000 18.000019.0000 21.200022.7000 24.400026.4000 26.400013.0000 32.100017.1000 37.800021.2000 20.800010.8000 24.600012.6000 28.400014.4000 18.000010.8000 21.900015.4000 25.800020.0000 16.200010.8000 21.000014.0000 25.800017.2000 16.200010.8000 21.000014.0000 25.800017.2000 14.20009.0000 18.300011.8000 22.400014.6000 EF 14.80004.4000 18.60007.8000 22.400011.2000 7.80001.8000 9.90003.4000 12.00005.0000 14.00006.2000 10.100017.7000 14.000021.4000 10.40005.4000 14.10008.9000 12.400017.8000 16.20009.2000 21.000012.2000 25.800015.2000 23.600019.6000 28.100023.7000 32.600027.8000 13.000016.6000 16.800020.1000 20.600023.6000 20.800027.6000 24.600033.7000 28.400039.8000 10.80005.4000 14.00007.0000 17.20008.6000 26.200024.6000 31.300030.6000 36.400036.6000 15.40008.4000 18.700010.1000 22.000011.8000 16.200018.0000 19.400022.1000 22.600026.2000 11.400019.0000 13.600024.1000 15.800029.2000 19.000017.0000 22.700022.1000 26.400027.2000 13.000014.8000 17.100018.1000 21.200021.4000 10.800017.4000 12.600021.5000 14.400025.6000 10.800021.2000 15.400026.2000 20.000031.2000 10.80005.4000 14.00007.0000 17.20008.6000 10.80005.4000 14.00007.0000 17.20008.6000 9.00004.4000 11.80005.6000 14.60006.8000 FG 17.00004.4000 20.50007.8000 11.200024.0000 1.80000.6000 3.40001.3000 5.00002.0000 14.00006.0000 17.70009.8000 21.400013.6000 10.40004.6000 14.10007.7000 17.800010.8000 9.20002.4000 12.20003.6000 15.20004.8000 19.600021.6000 23.700025.6000 27.800029.6000 16.600019.8000 20.100023.8000 23.600027.8000 27.600020.4000 33.700024.3000 39.800028.2000 5.40000 7.00000 8.60000 24.600022.0000 30.600026.3000 36.600030.6000 14.60008.4000 10.100017.8000 11.800021.0000 18.000026.6000 22.100033.1000 26.200039.6000 19.000010.4000 24.100012.3000 29.200014.2000 17.000020.8000 22.100026.1000 27.200031.4000 14.80009.6000 18.100013.4000 21.400017.2000 17.400023.4000 21.500028.7000 25.600034.0000 21.200010.0000 26.200012.9000 31.200015.8000 5.40000.4000 7.00000.7000 8.60001.0000 5.40000 7.00000 8.60000 4.40001.4000 5.60002.1000 6.80002.8000 GH 17.00008.4000 20.500012.1000 24.000015.8000 0.60009.2000 12.90001.3000 16.60002.0000 10.00006.0000 13.50009.8000 13.600017.0000 4.60006.6000 10.40007.7000 10.800014.2000 2.4000 3.60002.9000 4.80003.4000 21.600023.8000 25.600028.7000 29.600033.6000 19.800027.6000 23.800033.4000 27.800039.2000 20.400016.0000 24.300019.2000 28.200022.4000 3.20000 3.80000 4.40000 22.000020.6000 26.300024.3000 30.600028.0000 14.600010.0000 17.800013.4000 21.000016.8000 26.600014.8000 33.100019.9000 39.600025.0000 10.400022.8000 12.300028.2000 14.200033.6000 20.800021.2000 26.100026.7000 31.400032.2000 9.60004.0000 13.40005.4000 17.20006.8000 23.400016.0000 28.700019.3000 34.000022.6000 10.00008.4000 12.900011.2000 15.800014.0000 0.40001.2000 0.70001.7000 1.00002.2000 1.00000 1.40000 1.80000 1.40003.0000 2.10003.9000 2.80004.8000 H 8.4000 12.1000 15.8000 9.2000 12.9000 16.6000 10.0000 13.5000 17.0000 6.6000 10.4000 14.2000 2.4000 2.9000 3.4000 23.8000 28.7000 33.6000 27.6000 33.4000 39.2000 16.0000 19.2000 22.4000 3.2000 3.8000 4.4000 20.6000 24.3000 28.0000 10.0000 13.4000 16.8000 14.8000 19.9000 25.0000 22.8000 28.2000 33.6000 21.2000 26.7000 32.2000 4.0000 5.4000 6.8000 16.0000 19.3000 22.6000 8.4000 11.2000 14.0000 1.2000 1.7000 2.2000 1.0000 1.4000 1.8000 3.0000 3.9000 4.8000 Fuzzy Best Value F+ 17.000 20.500 24.000 32.400 42.000 51.600 5.000 8.600 12.200 4.600 7.700 10.800 32.400 42.000 51.600 24.200 28.700 33.600 27.600 33.400 39.200 27.800 34.500 41.200 32.400 42.000 51.600 26.200 31.300 36.600 24.400 29.100 33.800 12.200 14.200 16.200 29.000 36.600 44.200 14.600 17.400 20.200 4.000 5.400 6.800 26.600 32.800 39.000 8.400 11.200 14.000 27.000 33.100 39.200 32.400 42.000 51.600 29.800 38.800 47.800 Fuzzy Best Value F+ 17.000 20.500 24.000 32.400 42.000 51.600 5.000 8.600 12.200 4.600 7.700 10.800 32.400 42.000 51.600 24.200 28.700 33.600 27.600 33.400 39.200 27.800 34.500 41.200 32.400 42.000 51.600 26.200 31.300 36.600 24.400 29.100 33.800 12.200 14.200 16.200 29.000 36.600 44.200 14.600 17.400 20.200 4.000 5.400 6.800 26.600 32.800 39.000 8.400 11.200 14.000 27.000 33.100 39.200 32.400 42.000 51.600 29.800 38.800 47.800 Fuzzy Worst Value F- 4.400 7.800 11.200 0.600 1.300 2.000 17.200 20.800 24.400 19.000 22.400 25.800 0 0 0 15.000 18.300 21.600 13.000 16.800 20.600 15.600 18.700 21.800 0 0 0 19.000 22.400 25.800 8.400 10.100 11.800 26.600 33.100 39.600 10.400 12.300 14.200 21.200 26.700 32.200 26.400 32.400 39.000 10.800 12.600 14.400 27.000 35.100 43.200 0.400 0.700 1.000 0 0 0 1.400 2.100 2.800 Fuzzy Worst Value F- 4.400 7.800 11.200 0.600 1.300 2.000 17.200 20.800 24.400 19.000 22.400 25.800 0 0 0 15.000 18.300 21.600 13.000 16.800 20.600 15.600 18.700 21.800 0 0 0 19.000 22.400 25.800 8.400 10.100 11.800 26.600 33.100 39.600 10.400 12.300 14.200 21.200 26.700 32.200 26.400 32.400 39.000 10.800 12.600 14.400 27.000 35.100 43.200 0.400 0.700 1.000 0 0 0 1.400 2.100 2.800 FigureFigure A3.A3.Integrated Integrated Matrix Matrix Source: Source: Author’s Author’s ownown contribution.contribution. Figure A3. Integrated Matrix Source: Author’s own contribution. W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 0.36 0.466W1 0.42 0.257 0.31W2 0.252 0.209 0.124W3 0.171 0.104 0.062W4 0.085 0.067 0.037W5 0.069 0.429 0.579W6 0.456 0.28 0.21W7 0.332 0.193 0.014W8 0.014 0.096 0.07W9 0.07 0.45 0.496W10 0.537 0.299 0.298W11 0.252 0.146 0.119W12 0.126 0.103 0.086W13 0.083 0.459 0.125W14 0.13 0.229 0.071W15 0.26 0.14 0.125W16 0.13 0.097 0.071W17 0.055 0.072 0.047W18 0.033 0.666 0.666W19 0.666 0.333 0.333W20 0.333 0.36 0.466X1 0.42 0.257 0.31X2 0.252 0.209 0.124X3 0.171 0.104 0.062X4 0.085 0.067 0.037X5 0.069 0.429 0.579X6 0.456 0.28 0.21X7 0.332 0.193 0.014X8 0.014 0.096 0.07X9 0.07 0.45 0.496X10 0.537 0.299 0.298X11 0.252 0.146 0.119X12 0.126 0.103 0.086X13 0.083 0.459 0.125X14 0.13 0.229 0.071X15 0.26 0.14 0.125X16 0.13 0.097 0.071X17 0.055 0.072 0.047X18 0.033 0.666 0.666X19 0.666 0.333 0.333X20 0.333 A -0.2857 0.0765X1 0.4388 -0.3765 X20 0.3765 -0.3711 X30 0.3711 -0.0849 0.2358X4 0.5566 -0.3721 X50 0.3721 -0.2043 0.2312X6 0.6882 -0.3893 0.0458X7 0.4809 -0.3359 0.1328X8 0.6016 -0.3721 X90 0.3721 -0.3636 0.1818X10 0.7386 -0.1417 0.1850X11 0.5118 0.2482 0.4672X12 0.6861 -0.4497 X130 0.4497 -0.1932 0.2500X14 0.6932 0.5429 0.7714X15 1 -0.4397 X160 0.4397 0.3678 0.6437X17 0.9195 -0.3144 X180 0.3144 -0.3721 X190 0.3721 -0.3879 X200 0.3879 AB -0.28570.1837 0.07650.5459 0.43880.9082 -0.3765-0.0392 0.27450 0.37650.5882 -0.37110.2268 0.59790 0.37110.9691 -0.08490.2358 0.23580.5519 0.55660.8679 -0.3721-0.2054 0.13570 0.37210.4767 -0.2043-0.4839 0.23120.0323 0.68820.5699 -0.38930.0382 0.04580.3969 0.48090.7557 -0.33590.2344 0.13280.6172 0.60161 -0.3721-0.2054 0.13570 0.37210.4767 -0.3636-0.2841 0.18180.2443 0.73860.7841 -0.1417-0.1575 0.18500.1811 0.51180.5197 -0.14600.2482 0.46720 0.68610.1460 -0.4497-0.2604 0.14200 0.44970.5444 -0.1932-0.3182 0.25000 0.69320.3182 0.54290.2229 0.77140.3400 0.45711 -0.4397-0.1348 0.27300 0.43970.6809 0.36780.3736 0.64370.6868 0.91951 -0.3144-0.1907 0.09790 0.31440.3866 -0.3721-0.2054 0.13570 0.37210.4767 -0.3879-0.2543 0.10130 0.38790.4569 BC -0.01020.1837 0.54590.3571 0.90820.7245 -0.0392-0.2824 0.27450.0706 0.58820.4235 -0.11340.2268 0.59790.2680 0.96910.6495 -0.01890.2358 0.55190.3019 0.86790.6226 -0.20540.0659 0.13570.3624 0.47670.6589 -0.4839-0.4731 0.03230.0054 0.56990.5054 0.03820.0763 0.39690.4313 0.75570.7863 -0.52340.2344 0.61720 0.52341 -0.2054-0.0388 0.13570.2713 0.47670.5814 -0.28410.0227 0.24430.5057 0.78411 -0.15750.1417 0.18110.4449 0.51970.7480 -0.14600.0365 0.22630 0.14600.4161 -0.2604-0.1361 0.14200.2278 0.54440.5917 -0.3182-0.1250 0.43750 0.31821 0.22290.3086 0.34000.4571 0.45710.6057 -0.13480.1773 0.27300.5000 0.68090.8227 -0.03450.3736 0.68680.1552 0.34481 -0.1907-0.1392 0.09790.1778 0.38660.4948 -0.2054-0.0388 0.13570.2713 0.47670.5814 -0.2543-0.0172 0.10130.3017 0.45690.6207 CD -0.01020.2245 0.35710.5918 0.72450.9592 -0.2824-0.2078 0.07060.1373 0.42350.4824 -0.11340.2577 0.26800.6289 0.64951 -0.01890.3868 0.30190.6934 0.62261 0.06590 0.36240 0.65890 -0.47310.1398 0.00540.5591 0.50541 0.0763 0.43130.4466 0.78630.8168 -0.52340.0469 0.45310 0.52340.8594 -0.03880.1279 0.27130.4070 0.58140.6860 -0.20450.0227 0.50570.3239 0.86361 -0.37010.1417 0.44490 0.74800.3701 0.03650.0292 0.22630.2372 0.41610.4453 -0.13610.1598 0.22780.4822 0.59170.8047 -0.1250-0.1250 0.43750.2159 0.55681 0.30860.5600 0.45710.7629 0.60570.9657 -0.06380.1773 0.50000.2908 0.82270.6454 -0.03450.1149 0.15520.3075 0.34480.5000 -0.13920.0309 0.17780.3119 0.49480.5928 -0.03880.1279 0.27130.4070 0.58140.6860 -0.01720.1595 0.30170.4418 0.62070.7241 DE -0.27550.2245 0.59180.0969 0.95920.4694 -0.20780.4000 0.13730.6294 0.48240.8588 -0.30930.2577 0.62890.0773 0.46391 -0.25470.3868 0.69340.0566 0.36791 0.12790 0.40700 0.68600 -0.45160.1398 0.55910.0323 0.53761 0.07630.2672 0.44660.6336 0.81681 -0.02340.0469 0.45310.3867 0.85940.7969 0.12790.2946 0.40700.5426 0.68600.7907 -0.2045-0.5795 0.32390 0.86360.5909 -0.37010.0945 0.40940 0.37010.7244 0.02920 0.23720.1898 0.44530.3796 0.15980.3905 0.48220.6805 0.80470.9704 -0.1250-0.0682 0.21590.3011 0.55680.6705 0.56000.1771 0.76290.3343 0.96570.4914 -0.06380.4326 0.29080.7163 0.64541 -0.09200.1149 0.30750.1207 0.50000.3333 0.03090.2526 0.31190.4923 0.59280.7320 0.12790.2946 0.40700.5426 0.68600.7907 0.15950.3276 0.44180.5819 0.72410.8362 EF -0.27550.2959 0.09690.6480 0.46941 0.40000.5373 0.62940.7569 0.85880.9765 -0.30930.0928 0.07730.4691 0.46390.8454 -0.2547-0.0189 0.05660.3019 0.36790.6226 0.12790.3333 0.40700.5775 0.68600.8217 -0.4516-0.1935 0.03230.2688 0.53760.7527 0.26720.1527 0.63360.5076 0.86261 -0.0234-0.4688 0.38670.0312 0.79690.5313 0.29460.4612 0.54260.6783 0.79070.8953 -0.5795-0.5909 0.03980 0.59090.6818 0.09450.4961 0.40940.7480 0.72441 0.06570 0.18980.2883 0.37960.5109 -0.00590.3905 0.68050.3698 0.97040.7456 -0.0682-0.1818 0.30110.2670 0.67050.7159 0.17710.2286 0.33430.3629 0.49140.4971 0.43260.0355 0.71630.4007 0.76601 -0.09200.2069 0.12070.4310 0.33330.6552 0.25260.4742 0.49230.6727 0.73200.8711 0.29460.4612 0.54260.6783 0.79070.8953 0.32760.4957 0.58190.7155 0.83620.9353 FG -0.35710.2959 0.64800 0.35711 0.53730.5961 0.75690.7980 0.97651 -0.31960.0928 0.46910.0619 0.84540.4433 -0.0189-0.2925 0.30190 0.62260.2925 0.33330.5349 0.57750.7442 0.82170.9535 -0.1935-0.2903 0.26880.1667 0.75270.6452 -0.00760.1527 0.50760.3664 0.86260.7405 -0.4688-0.0156 0.03120.3984 0.53130.8125 0.46120 0.67830 0.89530 -0.5909-0.2500 0.03980.2841 0.68180.8295 0.49610.1339 0.74800.4449 0.75591 0.06570.3796 0.28830.6898 0.51091 -0.00590.4379 0.36980.7189 0.74561 -0.18180.0341 0.26700.4943 0.71590.9545 0.22860.0800 0.36290.2286 0.49710.3771 -0.26240.0355 0.40070.1454 0.76600.5532 -0.11490.2069 0.43100.0489 0.65520.2126 0.47420.6701 0.67270.8351 0.87111 0.46120 0.67830 0.89530 0.49570.5819 0.71550.7909 0.93531 GH -0.35710.0612 0.42860 0.35710.7959 0.59610.3098 0.79800.5706 0.83141 -0.3196-0.1134 0.06190.2526 0.44330.6186 -0.2925-0.1981 0.12740 0.29250.4528 0.53490.5620 0.74420.7578 0.9535 -0.2903-0.5054 0.16670 0.64520.5269 -0.0076-0.4427 0.36640 0.74050.4427 -0.01560.2109 0.39840.5977 0.81250.9844 0.54260 0.74030 0.93800 -0.2500-0.1023 0.28410.3977 0.82950.9091 0.13390.2992 0.44490.6181 0.75590.9370 -0.05110.3796 0.68980.2080 0.46721 -0.13610.4379 0.71890.2485 0.63311 0.03410.0568 0.49430.5284 0.95451 -0.08000.0800 0.22860 0.37710.0800 -0.26240.1418 0.14540.4787 0.55320.8156 -0.1149-0.1609 0.04890 0.21260.1609 0.67010.6392 0.83510.8093 0.97941 0.59300 0.78680 0.98060 0.58190.5388 0.79090.7522 0.96551 H 0.0612 0.4286 0.7959 0.3098 0.5706 0.8314 -0.1134 0.2526 0.6186 -0.1981 0.1274 0.4528 0.5620 0.7578 0.9535 -0.5054 0 0.5269 -0.4427 0 0.4427 0.2109 0.5977 0.9844 0.5426 0.7403 0.9380 -0.1023 0.3977 0.9091 0.2992 0.6181 0.9370 -0.0511 0.2080 0.4672 -0.1361 0.2485 0.6331 0.0568 0.5284 1 -0.0800 0 0.0800 0.1418 0.4787 0.8156 -0.1609 0 0.1609 0.6392 0.8093 0.9794 0.5930 0.7868 0.9806 0.5388 0.7522 0.9655 v 0.5 v 0.5 Alternatives Si Ri Qi Crisp Si Crisp Ri Crisp Qi

AlternativesA -1.2141 0.5283Si 2.4182 0.1243 0.1339Ri 0.3966 -0.6047 Qi0 0.6543 0.5774Crisp Si 1 0.2183Crisp Ri1 0.0165Crisp Qi1 -0.5931 0.9961 2.7619 0.0661 0.2544 0.4211 -0.5905 0.1507 0.7103 1.0550 2 0.2472 2 0.0902 2 AB -1.2141 0.5283 2.4182 0.1243 0.1339 0.3966 -0.6047 0 0.6543 0.5774 1 0.2183 1 0.0165 1 -0.3467 1.2465 3.0107 0.0707 0.2508 0.5370 -0.5614 0.1733 0.8346 1.3035 3 0.2862 3 0.1488 3 BC -0.5931 0.9961 2.7619 0.0661 0.2544 0.4211 -0.5905 0.1507 0.7103 1.0550 2 0.2472 2 0.0902 2 CD -0.34670.2558 1.24651.6942 3.01073.4000 0.07070.1282 0.25080.3237 0.53700.4638 -0.5614-0.4505 0.17330.2814 0.83460.8122 1.30351.7833 36 0.28620.3053 35 0.14880.2143 35 0.0179 1.4045 3.0359 0.1962 0.3614 0.5266 -0.4170 0.2837 0.8283 1.4861 0.3614 0.2317 DE 0.2558 1.6942 3.4000 0.1282 0.3237 0.4638 -0.4505 0.2814 0.8122 1.7833 65 0.3053 56 0.2143 56 0.5896 2.1152 3.6588 0.3072 0.4517 0.5963 -0.2638 0.4336 0.9516 2.1212 8 0.4517 7 0.3738 7 EF 0.0179 1.4045 3.0359 0.1962 0.3614 0.5266 -0.4170 0.2837 0.8283 1.4861 5 0.3614 6 0.2317 6 0.0897 1.2813 2.6366 0.1938 0.2634 0.4455 -0.4117 0.1876 0.7182 1.3359 4 0.3009 4 0.1647 4 GF 0.5896 2.1152 3.6588 0.3072 0.4517 0.5963 -0.2638 0.4336 0.9516 2.1212 8 0.4517 7 0.3738 7 H 0.5014 1.8701 3.3289 0.3950 0.5240 0.6531 -0.1981 0.4700 0.9661 1.9001 7 0.5240 8 0.4127 8 G 0.0897 1.2813 2.6366 0.1938 0.2634 0.4455 -0.4117 0.1876 0.7182 1.3359 4 0.3009 4 0.1647 4 H 0.5014 1.8701 3.3289 0.3950 0.5240 0.6531 -0.1981 0.4700 0.9661 1.9001 7 0.5240 8 0.4127 8 Figure A4. Fuzzy Difference Dij. Source: Author’s own contribution. Figure A4. Fuzzy Difference Dij. Source: Author’s own contribution. Figure A4. Fuzzy Difference Dij. Source: Author’s own contribution. Sustainability 2021, 13, 683 29 of 32

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