Factors Affecting the Attraction of Medical Tourists in Iran

Medical tourism is a new form of tourism that has seen increasing growth in recent years as an economic activity based on business services that link the two fields of medicine and tourism. Two of the most important issues to be considered in this regard are the marketing of medical tourism and the advantage of the relative competitive advantage. Therefore, the identification and prioritization of factors affecting the attraction of medical tourists might help to improve the quality and quantity of this new industry not only in Iran, but also in the world. From the viewpoint of academic experts in the field of tourism and medical tourism, physicians, hospital managers, and medical tourists, medical tourism in Iran is affected by service and welfare factors, advertising factors, physical factors, political and geographical factors, and human factors, respectively.


Introduction
After World War II, tourism was accepted in all social classes of Western industrial societies and was recognized as a modern collective phenomenon.Development in the field of tourism is possible through increasing living standards, reducing the annual work rate as well as the multiplicity of paid leave and rapid growth in transportation vehicles in industrialized western countries. 1edical tourism in Iran was first noticed by the Ministry of Health in 2003.Previously, the Ministry of Health had focused more on the issue of job creation for medical graduates and not on the development of medical tourism; gradually, however, after 2004 and the integration between cultural heritage organizations and Iranian and world tourism organizations, medical tourism was established independently in Iran. 2 Health tourism in general, and medical tourism in particular, is a type of tourism that takes place for longer than a day to maintain, improve, or regain the physical and mental health of the individual.If the goal is to travel to villages and areas with mineral springs and hot water in order to escape the stresses of everyday life and rejuvenate without medical intervention or supervision, and in cases where the tourist does not have a definite physical illness, travel is considered as health tourism. 3If travel takes place in order to use natural resources (mineral waters, salt, sludge, etc.) for the treatment of certain illnesses or to spend the recovery period under the supervision and intervention of doctors, it is considered therapeutic tourism.If travel is for the treatment of a physical illness or to obtain some kind of surgical procedure under the supervision of doctors in hospitals or treatment centers, it is considered medical tourism. 4imultaneous attention to the systematic policymaking and support of active groups in this business is possible through developing a comprehensive strategy and increasing the availability of medical services and health and therapeutic tourism services to foreign patients. 5ealth and medical tourism are promising industries and income sources for countries.The factors attracting health tourists to Iran must be identified based on the market competition in the world; then, regional or international plans must be maintained.So far, several studies have been conducted on the factors and dimensions affecting the medical tourism industry.Their results have shown that the specific features of each country, including economic conditions, the political climate, and regulations, affect the selection of tourists.Also, factors such as costs, hospital credit, quality care of the patient, and physician's expertise affect a tourist's selection of medical facilities.In this research, the factors affecting medical tourism were investigated and prioritized, and a detailed review of the role of hospitals in attracting medical tourists in particular was made. 6oday, countries that plan to expand their gross national income by expanding the service market consider tourism to be the most important market with turnover, productive employment, and high marginal income. 7

Consequences and Goals of Medical Tourism
A "medical tourist" is a person who travels to the host country to receive medical and tourism services -a tourist trip with the incentive to receive health services along with spending leisure time."Patient for leisure" is the person who chooses the host country for the purpose of receiving medical services, but suddenly utilizes leisure services, especially during recovery or following a specific surgery or treatment.Finally, a "patient" is a person who chooses the host country only for medical services. 8t seems that Iran is not currently among the most attractive medical tourism destinations, but it is now taking its first steps towards becoming one.Therefore, researching this issue is even more necessary and important.The variety, proper quality, and low cost of healthcare services in Iran, taking into account the geographical situation of the country, are among the effective factors in attracting medical tourists.Among the factors reflecting the necessity of this research in order to increase the level of attraction and loyalty in this area is the appropriate practice of the relevant organizations, especially health centers in various areas, such as the introduction of health care services, easy patient admission, and specialized teams familiar with using a professional approach with patients.It must also be noted that developing medical tourism without the necessary controls may negatively impact the health system of the host country. 9wo related dimensions of development that facilitate the demand for medical tourism are service compilation and globalization of services.Compilation is a process that moves the market from a unique product into market-driven competition, in which production reaches the point where the domain can take steps towards economic liberalization.According to the definitions given in the General Agreement on Trade in Services (GATS), the scope of business services is very wide and encompasses all aspects of the triangle of economic globalization, i.e. trade, investment, and migration. 10ecause of increasing globalization, the main objective in the field of health in Iran's fourth and fifth development plans is active participation in global markets aimed at job creation, quality development in the health sector of the country, convergence with world standards, increasing earned income, supporting economic growth, and becoming a medical tourism hub in the region.In Article 29 of the general policy of the fifth development plan, in the economic affairs chapter, emphasis has been placed on the export development strategy, especially in the high-tech sector, in order to reduce the deficit of nonoil trade and establish a balance of trade in goods. 11n terms of goals, medical tourism can be defined as the supply of cross-border medical services in combination with other tourism products relying upon the competitive advantage. 12he purpose of medical tourism is to obtain obligatory or elective medical treatment at a foreign destination.The term "obligatory treatment" refers to the immediate and unplanned treatment of dangerous diseases, while "elective treatment" refers to unnecessary procedures. 13edical tourism has grown for several reasons.Various studies have suggested that the main reasons for the development of the medical tourism industry are increases in waiting lists in advanced countries, increased rates of international exchanges, the Internet (with the development of the communication network, new companies have been established as the interface between international patients and the hospital network providing basic information to patients), low-cost services in developing countries, technology, and modern equipment compatible with new health services. 14,15  addition to the cost and reputation of facilities and treatment centers, Bristow et al. (2011) mentioned hospital accreditation, physicians' reputations, postoperative opportunities (recovery), the culture of the country, the dependence of facilities on advanced hospitals in developed countries, and the lack of some health services in the country among the factors affecting consumer behavior.In recent years, consumers have started browsing the Web to access information on health and health measures available to them.Several studies have shown that e-mail has become a tool for purchasing products and services.Even on some attractive websites, consumers can contact their specialists or surgeons and plan their flights, facilities, and tourist packages. 18stimates show that every medical tourist produces three times more income than a normal tourist 19 .The financial volume of the industry was estimated at $148 billion in 2015, and the world's average revenue from medical tourism was $327 billion. 20

Factors Attracting Medical Tourists
Medical tourism to Iran has been considered for many years by patients from various areas, including the Gulf States.Due to Iran's cultural, ethnic, and geographical proximity, they refer to border regions like Fars, especially the city of Shiraz, for its modern facilities. 21,22 cent years have seen patients from Azerbaijan and Iraq referring for medical services in the northwest of Iran, especially in the metropolis of Tabriz.In sum, Iran's largest medical group of tourists are from the Persian Gulf States and Central Asia.][25] One main reason medical tourists are attracted to foreign destinations for medical services is the long period patients must wait to receive medical treatment in their countries of origin.This is especially evident in western countries.Studies have reported the shortest waiting periods are in the European countries of the Netherlands, Denmark, and Sweden, and the longest waiting periods are in Canada and the United States.According to Kelley (2013), the most important reason medical tourists are attracted is the availability of more advanced technologies in the destination country. 26ther reasons are the better quality of surgical procedures, which accounts for 2%, and finally, rapid access to medical treatment, with 51% of the population choosing a foreign country as a tourist destination.It is also worth noting that the least important reason is the lower costs of medical treatment in the destination country. 27iven the high financial potential in this industry, today, many developing countries in Asia, South America, and Africa are competing to attract medical tourists.Of course, it is difficult to set out the popular destinations of medical tourism, because each country is superior to other countries in a particular field; yet, in general, the major destinations of the world's medical tourists include the countries of Costa Rica, Mexico, the USA, Singapore, Thailand, Malaysia, India, the Philippines, Taiwan, South Korea, and Turkey. 28n the context of political culture, most patients are only attracted to areas where the host country has a high level of security and its political system is protected from corruption and violence.Regarding social behavior, the feelings and behavior of the local residents towards tourists in general and medical tourism in particular play a special role in attracting foreign patients. 29According to Smith and Forgione (2007), foreign patients are willing to travel to countries in which they feel comfortable with the local communities and do not face limitations.American patients are often sensitive to a host country's laws and regulations.For example, the US healthcare system fully protects US patients through accredited and accountable insurance; therefore, American patients are primarily targeting those countries which enjoy the same system as their own. 30n a study by Palvia (2008), internal factors of the second stage include four effective factors: costs, accreditation, quality of services, and trained physicians. 31

Prioritizing Factors Affecting the Attraction of Medical Tourists
The first factor of attracting medical tourists is the cost of health services.Given that the cost of treatment in the United States is very high, patients travel to other countries for cheaper healthcare.The second and third factors in this area are hospital accreditation and the quality of healthcare . 32The first issue that comes to an American patient's mind is probably the quality or the credibility of the hospital.Many American patients are attracted to hospitals which have the same standards and quality of health services as those in the United States.The last factor that Palvia refers to is trained and experienced physicians.He believes that a hospital without doctors and trained professionals cannot be appealing to American patients. 31,33 other important factor in medical tourism is marketing. 34International marketing is defined as the activity of large companies, in which products (services) move from marketers to consumers (users) in different countries.Because of the nature of tourism, a comprehensive definition of its marketing is somewhat difficult.Because changes and developments and, consequently, the prediction of future market conditions are very difficult and depend on many factors, including economic, social, and political conditions, tourism marketing is an interactive process between suppliers and consumers (tourists) in which goods and services are traded in an environment specific to the industry. 35,36 nsidering the specific features of tourism products, the role of marketing in this industry is of particular importance compared to other industries, and the use of effective marketing tools for a country or region is essential, because marketing can provide potential tourists with information about what the region could offer while encouraging them to visit. 37n Iran, due to the numerous potential sources of tourism attraction, there have been many efforts to develop this industry.Among them are the comprehensive national tourism development plan and various comprehensive provincial plans that, given the strengths and advantages of each region, organize the general policies, the regional and provincial strategies of tourism development in the country, and the framework and basis for other tourism development plans and programs.It is clear that the success of large-scale projects is due to the development of programs for the implementation and operationalization of anticipated policies and proposed strategies in these projects. 38nother strategy of tourism is that of urban tourism development.Cities often contain a wide range of historical and cultural sites, markets, restaurants, hotels, and urban parks.Many attractions and amenities of urban welfare have essentially been developed to serve citizens, while cities may be the gateway to the arrival and departure of tourists to a country or region and serve as a base for tourists traveling to surrounding areas. 39oday, it is common to construct or redevelop some urban areas used by tourists and by inhabitants during their leisure time.Other strategies include rural tourism development strategies like the one in Senegal and the development of religious tourism strategies in Saudi Arabia. 40

Conclusion
Medical tourism is a combination of medical and residential services which is a two-way correlative process.The motivations of medical tourists, in addition to reduced medical costs and advanced facilities of hospitals, include hospital accreditation, physicians' reputations, culture, and the lack of medical services in the country of origin.One main influence on the attraction of medical tourists is the long waiting time for patients to receive medical treatment in the country of origin.To attract medical tourists, in addition to medical centers, many organizations and institutions must pursue common goals and strategies through coordination and goal-setting.It seems that the prioritization in attracting medical tourists includes cost of treatment, waiting time, quality of healthcare and accommodations, security, easy admission to medical centers, simple visa requirements, physicians' reputations, geographical distance, country culture, and the experiences of other tourists.Finally, the attraction of medical tourists is a process of political and cultural exchanges in addition to economic ones.