Strategies for Medical Tourism Development in Khuzestan Province, Southwest of Iran ‎ ‎

INTRODUCTION

Tourism is a leading and diverse industry in the world. It is one of the main sources of income for countries [1]. Based on the experts’ prediction, this industry will become the most profitable industry in the world by 2020. Increased international growth, global competition and interest in tourism destinations have led to the emergence of various types of tourism [2, 3]. Nowadays, many countries have expanded and improved their medical industry as a major source of tourism-related income, given the human need for health [4]. An annual increase of 20% in the treatment of foreign patients by USA hospitals confirms this issue. Medical tourism is a new type of tourism and international and an economic-political phenomenon that is growing, especially in Asian countries [5]. Investment in the medical industry is a way to increase GDP, improve service, generate foreign exchange, and create a better balance in trade and tourism. Many countries have recognized the business opportunities resulting from medical travels, especially since they have been mixed with the tourism industry. Given the advantages of medical tourism in this regard, the low cost of services, appropriate equipment, and competent physicians and having various historic attractions and high therapeutic capabilities, it can use the opportunities of the health service market [6, 7]. Due to its unique characteristics such as high quality of medical services, low costs of drug and treatment, access to advanced services and equipment and the presence of skilled specialists, the medical tourism industry in Iran can respond to the needs of the tourists. However, there are some problems in the medical tourism industry of Iran, such as weakness of the medical tourism informing portal, the presence of problems at the level of policy-makers and managers, the presence of dealers as intermediaries between the patients and medical centers, patients' dissatisfaction, lack of post-treatment cares, lack of standard insurance policies following the global standards and marketing plans, continuous change in world technologies, poor rules in medical crimes, appearance of the medical centers and hospitals [4, 8].

Lifesky and Myers (2008) argue that the ability to attract tourists in the health sector and the international market depends entirely on the ensured quality [9]. Jabbari et al (2006) also suggest that patients who are in the long-term lists or do not use health insurance seek their needed services in the developing countries [10]. If medical tourism is considered as a priority, Iran would be potentially able to prevent the waste of currency and manpower [11]. Factors such as a change in consumer values, changes in construction, aging population and health care system requirements can be considered as the main causes of the medical tourism emergence. A set of factors have caused the medical tourism to become one of the growing tourism kinds [12]. Global statistics suggest that Arab countries are the best option to attract medical tourists. A 245 million population of 17 Arab countries and the lack of adequate specialized services have caused thousands of Arab patients to travel to other countries each year so that 6000 UAE patients refer to international hospitals. Due to security problems, a small presence of health-care investors is seen in Iraq. Hence, Iran is a suitable country for attracting people to use medical services [13]. Khuzestan Province is a major city in providing medical services in the South West of Iran and includes several medical centers and hospital beds. It also provides a variety of clinical and paraclinical services and skilled and experienced physicians as well as advanced medical equipment at the national and international levels. Also, due to its proximity to the Arab countries and shared culture and language with most of them and having foreign and domestic tourists, Khuzestan Province is one of the major medical tourism provinces which requires paying more attention and investment in tourism industry and strengthening its health sector infrastructure to gain more profit in this high-income market. Hence, the present study aimed to determine strategies for medical tourism development in Khuzestan province.

METHOD

This study was a qualitative research conducted in 2019. The research population included all experts in medical tourism in Ahvaz Jundishapur University of Medical Sciences. The research inclusion criteria included having at least 10 years of employment history as well as sufficient knowledge and experience in different levels of medical tourism. Data were collected through questions about medical tourism strategies in Khuzestan province. In the present study, the textual data were reported and analyzed by the content analysis method. Based on this method, the main domains and different components of the domains were extracted from the raw data and they were coded. The interviews were transcribed immediately after their implementation and were used for qualitative content analysis. Interviews continued until data saturation. Before coding the concepts, the entire text was read several times so that the researchers obtain full knowledge of the data. Then, semantic units and initial codes were extracted from the raw data.  After coding, the initial codes were categorized and similar codes were sub-categorized. Interviews were categorized into the main domain and components of each domain. The members of the research group coded some interviews separately and the similarity of the codes was examined and a consensus was reached on the difference. In the present study, ethical principles such as confidentiality of information, obtaining the informed consent to be interviews, and giving the right to withdraw from the research at any stage were observed by researchers. The results were categorized and analyzed manually without using the software.

RESULTS

To obtain tourism development strategies in Khuzestan province, in analyzing the questions, after deleting the duplicate codes and merging the similar cases, 15 codes were obtained and they were categorized into 5 main themes (administrative-executive, economic, reforming and revising the rules and regulations, marketing and informing) and 48 sub-themes.

The administrative-executive strategies of tourism development in Khuzestan province are as follows (Table 1).

Table 1: administrative-executive strategies of tourism development in Khuzestan province

Table 1 shows the most important administrative-executive tourism development strategies of Khuzestan province, ranking the health service centers, obliging of service centers to obtain a license from international organizations such as JCI and determining the medical service tariff as foreign exchange for the foreign patients. The economic strategies for tourism development in the Khuzestan province as follows: (Table 2).

Table 2: The economic strategies for tourism development in the Khuzestan province

Table 2 shows the most important economic strategies of tourism development in Khuzestan province, including reducing the customs tariff of medical equipment for the centers and hospitals active in providing service for the foreign patients and encouraging and attracting direct foreign investment in the treatment sector. The strategies for revising and reforming the rules and regulations of tourism development in Khuzestan province are as follows (Table 3).

Table 3: The strategies for revising and reforming the rules and regulations of tourism development in Khuzestan province

Table 3 shows that the most important strategies for reforming and revising tourism development rules and regulations in Khuzestan province include a visa issuance process for medical tourists, removing the transferability barriers of foreign insurances and observing the rights and security of the tourists. The marketing strategies of tourism development in Khuzestan province according to the respondents are as follows (Table 4).

Table 4: The marketing strategies of tourism development in Khuzestan province

Table 4 shows that the most important marketing strategies for tourism development in Khuzestan province include identifying target markets in the region with shared culture, religion, language, and geographical proximity, and so on, signing contracts with other countries for patients' referral to these hospitals after treatment and establishing relevant government agencies in target markets countries. The strategies of informing, advertising and promoting of internal services of tourism development in Khuzestan province according to the respondents are as follows (Table 5).

Table 5: The strategies of informing, advertising and promoting of internal services of tourism development in Khuzestan province

Table 5 shows the most important strategies for marketing, advertising, and promoting internal tourism development services in Khuzestan province. They include directing the need for health services towards internal resources, forming a tourism informing portal in Ahvaz, building trust on the quality of services provided at the province by obtaining international licenses and accreditations, and updating and recording of health tourist statistics and information.

DISCUSSION

The results of the study revealed that the most important strategies for tourism development in Khuzestan province included 5 main themes (administrative-executive, economic, reforming and revising rules and regulations, marketing and informing). In a study entitled "Evaluation of the factors affecting medical tourism development (Case study: Hamadan City)", Khalajian et al (2016) concluded that general conditions, personnel, medical equipment, and website standards were the influential factors in the development of medical tourism in the Hamadan city according to the hospital managers [14]. The results of the study revealed that the most important administrative-executive strategies of tourism development in Khuzestan province include ranking the health service centers and obliging health service centers to receive a license from international organizations such as JCI and determining medical service tariff as an exchange for the foreign patients.

In a study entitled "Health strategic empowerment, and tourism development in Ahvaz", Ghanbari Adivi and Sharifi (2018), results consistent with the results of the present study were obtained. Their results revealed that standardization of medical services following international standards was a strategy identified as a top priority in the executive-administrative indicator for the development of medical tourism.  Adhering to standards and receiving international licenses such as JCI make them be in the list of standardized healthcare centers at the global level and it is the best marketing tool. Communication of these centers with other hospitals and centers facilitates the provision of the services for the patients [15].

Results of the study revealed that the most important economic strategies for tourism development in Khuzestan province include reducing customs tariffs of medical equipment for centers and hospitals that are active in providing services for foreign patients and encouraging to attract foreign direct investment in the health sector.  The high cost of health care in developed countries makes people look for cheaper care in other countries that are economically less-developed. The difference in treatment prices among these countries and the developed countries is very high, leading people to travel to these countries. Cheaper treatments are highly attractive in some countries due to certain conditions.  This situation has created a potentially large market for cheap medical equipment in other countries [16].

Results of the present study indicated that the most important strategies for reforming and revising tourism development rules and regulations in Khuzestan province include the visa-issuance process for medical tourists and removing the barriers of transferability and security of the foreign insurances and observing the rights and security of the tourists.  Gonzalez argues that strengthening legal frameworks to ensure consumer protection and high-quality care as one of the critical factors in the development of the medical tourism industry [17]. Porter et al. also argue that establishing an insurance system for medical tourists is essential in the development of Philippine medical tourism [18].

 Smith and Foreign (2008) investigated the growing trend of medical tourism and identified different factors influencing the decision of the patients on health care services around the world.  They concluded that economic conditions, political conditions and standards, and rules are effective in the selection of the destination by the patients. Also, they identified four important factors in selecting a hospital by the patients. They included costs, credit, hospitals, quality of health care, and training of medical staff [19]. The most important marketing strategies for tourism development in Khuzestan province included identifying target markets in the region with shared culture, religion, language, and geographical proximity, and so on, signing contracts with hospitals of other countries for patients’ referring to those hospitals after the treatment and establishment of government representative offices in the countries of the target markets.

 In a study conducted by Hung, similar results were obtained and two factors of culture and government showed a significant impact on attracting health tourists and selecting the tourism destinations in the Philippines [20]. In the research conducted by Zarei et al (2016) to assess the social marketing in medical tourism, it was revealed that improving the components such as transportation status, advertising, expertise, communication, security, cost, attractiveness, and facilities can be effective in designing effective social marketing mix.  Given the confirmed effect of social marketing strategies on the social marketing mix, it is expected that formulating the marketing strategies based on analysis of the market, landscape, internal environment, and target markets to affect the integrated implementation of the marketing mix. Social marketing can play a vital role in medical tourism by creating a good image in the minds of people. Thus, senior managers of organizations must pay attention to the vital role of social marketing [21]. The research results suggest that the most important strategies for informing, advertising and promoting internal services of tourism development in Khuzestan province include directing the need for health services towards internal resources, forming a tourism informing portal in Ahvaz, building trust on the quality of services provided at the province by obtaining international licenses and accreditations, and updating and recording of health tourist statistics and information.

In a study entitled “The relationship between informing and attracting medical tourists in private hospitals in Isfahan”, Ayubia (2011) argued that among the informing mechanisms variables, only mass advertising has a significant relationship with attracting medical tourists [22]. It means that advertising of the country’s capabilities in foreign countries’ media in the field of health care services, physicians, and topology can result in attracting medical tourists [23]. Ghalami (2009) reported that welfare facilities and capabilities of medical centers in the international media, informing the embassies of the country and providing brochures and pamphlets to foreign tourists, participation of the medical centers in international exhibitions, establishing informing portal and preparing medical centers and installing posters in the international airports of the country are effective in promoting the export of health services in the advertising sector [24].

CONCLUSION

According to experts and experts of Ahvaz Jundishapur University of Medical Sciences in the field of medical tourism, the most important strategies for medical tourism development in the Khuzestan province include ranking the health service centers, obliging of service centers to obtain license from international organizations such as JCI, facilitating the issuance of visas for medical tourism, identifying target markets in the region with shared culture, religion, language, and signing contract with other hospitals for patients’ referring to these hospitals after treatment, signing contract with other hospitals for patients’ referring to these hospitals after treatment, directing the need for health services towards internal resources, and to establish a medical tourism informing portal in Khuzestan province. Therefore, it is recommended for policymakers and decision-makers of the Khuzestan medical tourism industry to take steps based on the priorities identified to enhance and promote medical tourism in Khuzestan province.

Executive recommendations

• Reviewing and reforming rules to facilitate the attraction of the health tourists
• Reducing and eliminating of brokers and middlemen in medical tourism
• Prioritizing advertising programs on health and medical tourism in Khuzestan province (such as introducing this province to international medical tourism conferences and seminars)
• Installing guideline boards and providing comprehensive and accurate information on the culture, history and cultural heritage of Khuzestan Province in medical centers and tourism hotels in several foreign languages
• Training of human resources and holding specialized courses in English and Arabic languages within the framework of medical and treatment service as a practical strategy
• Providing hotel apartments for patients to spend their recovery period or guide the patients to adjunct standard hotels and providing transportation standards for the patients
• Taking some measures for post-treatment follow-ups and patients’ communication with medical centers during their recovery period.
• Establishing a medical tourism database for better management and planning in the required areas.

REFERENCES

1. Connell J. Medical tourism: Sea, sun, sand and… surgery. Tourism management. 2006 Dec 1;27(6):1093-100.
2. Sharifabadi AM, Ardakani FA. A model for health tourism development using fuzzy TOPSIS and interpretive structural modeling in Yazd province. Journal of Health Administration (JHA). 2014;17(55).
3. Taie ES. Emerging of medical tourism in Egyptian hospitals: International patient satisfaction towards nurses services quality. Global Adv Res J Manag Bus Stud. 2013;2:93-104.
4. Nasirpour A, Salmani L. The role of Tehran hospitals ability in the developing medical tourism. Hospital Journal. 2010;9(3):57-67.
5. Haung CY, Wang SP, Chiang CW. Cost feasibility of a pre-checking medical tourism system for US patients undertaking joint replacement surgery in Taiwan. Chang Gung Med J. 2010 Nov 1;33(6):684.
6. Heung VC, Kucukusta D, Song H. A conceptual model of medical tourism: Implications for future research. Journal of Travel & Tourism Marketing. 2010 Apr 30;27(3):236-51.
7. Izadi M, Ayoobian A, Nasiri T, Joneidi N, Fazel M, Hosseinpourfard MJ. Situation of health tourism in Iran opportunity or threat. Jl Mil Med. 2012 Jul 15;14(2):69-75.
8. Mostafavi H, Shamsi E, Abbasi M. Ethics in Health Tourism. Journal of Bioethics. 2013; 2(4): 161-80.
9. Lagiewski R, Myers William. Medical tourism: Perspectives and applications for destination development, 2008. American College of Management and Technology. Accessed From URL: http://scholarworks.rit.edu/other/683. Last Access: Sep 22, 2016.
10. Jabbari A, Shafaghat T, Rahimizarchi MK, Kavosi Z, Keshtkaran A. Medical tourism in Shiraz. International Journal of Health System and Disaster Management. 2013 Jan 1;1(1):43.
11. Ezadi M, Ayyoubian A, Nasiri T, Joneidi N. State of health tourism in Iran, opportunities and threats. Military Medicine. 2012;14(2):69-75.
12. O'Reilly P, Carter RW. A rapid appraisal methodology for environmental auditing. Journal of Tourism Studies. 1999 Dec;10(2):14.
13. Khoshkho MI. Feasibility Assessment for Tourism Development in Persian Gulf (A Case Study of Hendourabi Island). European Journal of Scientific Research. 2011;61(1):108-
14. Khalajian H, Azadi Y and Hosseinzadeh J. Investigating Factors Affecting Health Tourism Development Case Study: Hamadan City, 21^st Century International Conference on New Approaches in Human Sciences, Rasht, Conference Secretariat, 2016. https://www.civilica.com/Paper-ICNAH01-ICNAH01_069.html
15. Ghanbari Adivi K and Sharifi A. Health Tourism, A Powerful Strategy for Ahwaz Metropolitan Tourism Development, 21^st Century National Conference on Urban Management and Architecture, Karaj, Permanent Secretariat of the Conference, 2018. https://www.civilica.com/Paper-ENGGCONF01-ENGGCONF01_077.html
16. Jabbari A. Designing a Model for Iran Medical Tourism [Ph.D. Thesis]. Tehran: Iran University of Medical Sciences, School of Management and Medical Informatics; 2009.
17. Gonzales A, Brenzel L, Sancho J. Health tourism and related services: Caribbean development and international trade. Final report. 2001 Aug:57-8.
18. Rxpinoy.com [homepage on the Internet]. Porter EM, Vera MD, Huang B, Khan O, Qin Z, Tan A. Medical tourism in the Philippines. Philippine: c2007-2010 [updated Jun 2011]. Available form: http://www.rxpinoy.com/medicaltourismphilippines/index.php
19. Smith PC, Forgione DA. Global outsourcing of healthcare: a medical tourism decision model. Journal of Information Technology Case and Application Research. 2007 Jul 1;9(3):19-30.
20. Heung VC, Kucukusta D, Song H. A conceptual model of medical tourism: Implications for future research. Journal of Travel & Tourism Marketing. 2010 Apr 30;27(3):236-51.
21. Zarei, A., Azar, A., Rezaei Rad, M. Measurement of Social Marketing in Health Tourism. Journal of Tourism Planning and Development, 2016; 5(18): 33-53.
22. Ayoubian A, Tourani S, Hashemi Dehaghi Z. Medical tourism attraction of Tehran hospitals. Int J Travel Med Glob Health. 2013 Sep 1;1(2):95-8.
23. Agharahimi Z. Study of medical tourism industry in selected countries and presentation on suggestions for Iran [MSc thesis]. Tehran: Tehran University of Medical Sciences, Faculty of Medicine; 2010.
24. Ghalami S. Study of solutions to improve Iran's position in the exporting health care services marketing and attracting of medical tourism [MSc Thesis]. Tehran: Tarbiat Modarres University, School of Management; 2010.