Identifying and Ranking Health Tourism Development Barriers in Iran Using Fuzzy VIKOR Method

The present research is an applied study which employed a descriptive-correlation method. After a review of the related literature and survey of opinions of health tourism industry experts, the considered criteria in evaluation and ranking health tourism barriers were determined. Subsequently, 4 criteria (price, quality, accessibility, and proper time) were selected as the most important criteria. Using purposeful sampling method, out of cities and regions with health tourism attraction, four cities were selected as the most important cities with health tourism attraction. Using Fuzzy VIKOR method, quality was found to be the highest importance and proper time was determined as the lowest important criterion. Among sub-indices, improper medical quality was found to have the highest importance (weight). Among the selected cities, Mazandaran was found to have the highest priority. Shiraz, Tabriz and Mashhad, then, had the highest importance, respectively, in terms of health tourism development barriers.


Introduction
Generally, a travel with at least one night residence in destination is called a tourism travel.This definition is an arbitrary definition and several matches have been performed to present a comprehensive definition for tourism, but all have failed (Rahnama, 2002).

Health Tourism
There are various definitions for health tourism: 1. Trips which people take in order to benefit from climatic change (with a medical purpose), use mineral waters, convalesce from an illness, receive therapy, and so forth (Rezvani, 2000).Most patients also refer to important medical centers in developed countries with high healthcare facilities.This kind of tourism is highly common and frequent (Mahalati, 2001).
2. According to World Tourism Organization (WTO), health tourism is using services which improve or increase health and spirit of people (through mineral waters, climate or medical interventions) and is performed out of the residential place for more than 24 hours.
3. Travelling from one country to another country to receive medical services in hospitalization unit or outpatient department including: a. Outpatient services, such as checkup, disease diagnosis, etc., which can be provided for less than 24 hours.
b. Hospitalization services which take a time longer than 24 hours (legal office of health ministry, health tourism law) One of the most important goals of health tourism is to travel to retrieve power (Heraheshe, 2000).WTO particularly defined health tourism as the use of health tourism in using services which improve or increase health and spirit of people (through mineral waters, climate or medical interventions) and is performed out of the patient's residential place for more than 24 hours.2. Obtaining international quality accreditation (JCI) by hospitals and medical centers 3. Education and reference system of professional medical personnel 4. Recoding, controlling and survey system for cured foreign patients  Indices related to medical tourism services providers 1.A specialist system of referring foreign patients 2. The presence of various service packages (supplemantary goods basket) for foreign patients 3. the process of receiving service and the possibility of detecting therapeutic stages of foreign patients 4. developing human force (trained medical personnel, having good knowledge of patients' language, skillful in social relations) 5. The presence of service quality standards (medical and tourism) 6. Designing an optimal balance system of beneficiaries of medical tourism scope of the country (Beygi Firouzi, 2011)  Indices related to tourism service providers 1.The information about medical centers, surgeons, etc.
2. The access and possibility of using distribution channels and international sales 3. The presence of infrastructures of accepting foreign passenger 4. The process of receiving Visa (for medical purposes) In the following discussion, there are some instances of previously conducted studies in this regard.
Izadi (2012) investigated health tourism status and determined special advantages for Iran.As he reported, Iran has numerous advantages such as experienced and skillful physicians, modern technology and natural medical regions to attract health tourists.It has, however, some weaknesses such as inappropriate coordination between organizations in charge of medical tourism and inappropriate planning.Houshmandi (2012) investigated the potentials of medical tourism in dry and semi-dry regions of Iran.He concluded that some factors such as sun radiation more than 300 days in a year, warm and mineral water springs, hot sand hills, therapeutic mineral soils, evaporative salts and sediments, salt caves and sludge with healing property can lead to the attraction of tourists, increase entrepreneurship and remove poverty in these regions.Viladrich (2014) explored the role of e-marketing in health tourism development in Argentina for reconstructive surgeries.In his study, he observed that in Argentina, besides health tourism services, tango dance is one of the factors attracting tourists to this country.Given the importance of the issue, the research questions addressed in the present study can be stated as follows: The main research question: What are health tourism barriers in Iran?

Secondary research questions:
1. To some extent health tourism development barriers in Iran are important?

Methodology
The present research was an applied study which used the descriptive-correlation method.First, the related literature was reviewed and the opinions of 12 health tourism industry experts were surveyed, and then the considered criteria in evaluation and ranking health tourism barriers were determined.Finally, 4 criteria were selected as the most important criteria.Using purposeful sampling method, out of cities and regions with health tourism attraction, four cities were selected as the most important cities with health tourism attraction.The most important criteria considered in this study are as follows: To rank the health tourism development barriers as well as rank the four selected cities, we employed Fuzzy VIKOR method.

Fuzzy VIKOR Method
Fuzzy VIKOR method is an adaptive MADM method developed by Opricovic and Tzeng (2002).They developed this method based on LP-metric method.* / * 1 ∞; 1,2, … . .This method can provide a collective desirable maximum value for majority and a minimum individual effect for opposites.The stages of this method are as follows: Computing normalized values: suppose that there are m alternatives and n criteria.Various alternatives have been determined as xi.For the alternative xj, the rank j th has been determined as xij and for other alternatives, xij is the value and j th the criterion.
In the so-called method, linear normalization is used to make decision matrix dimensionless.This will be done in computational formula of the studied method.
Determining the best and the worst value: the best and the worst of each value in each criterion are identified and called * and , respectively.
Where * is the best positive ideal solution for the j th criterion and is the worst negative ideal solution for the j th criterion.If all * are lined together, we will have an optimal combination with the highest score.It is also true about .
Determining weight of criteria: criteria' weight should be computed to determine the importance of their relations.In this regard, the present study will use FAHP method.
Computing the distance between alternatives and ideal solution: this stage of computing the distance of each alternative from ideal solution and then their sum for the final value is performed based on the following relations: Where Si indicates the ratio of the distance of the i th alternative from the positive ideal solution(the best combination) and Ri indicates the ratio of the distance of i th alternative from the negative ideal solution(the worst combination).The best rank is obtained based on Si value and the worst rank is obtained based on Ri value.In other words, Ri and Si are the same L1i and L.i, respectively, in LP-metric method.
Computing Qi value: for each of is, this value is defined as follow: * * 1 * * * ‫و‬ ‫و‬ * ‫و‬ Where, v is strategy weight of the maximum agreed with the criterion or the minimum collective desirability.
Ranking alternatives based on Qi values: in this stage, we rank alternative and make decision based on Qi values computed in the previous step.

Descriptive Statistics
According to demographic information, 83.4% of the sample composed of males and 16.6% of females.Further, 4.4% of the sample were 20-30 year-olds; 30.6% were 30-40 year-olds; 30% accounted for 40-50 year-olds, and 35% represented above 50 year-olds.Finally, 28.1% of the sample held a bachelor's degree; 46.3% held a master's degree and 25.6% had a PhD or above.

Inferential Statistics
Table 1 shows verbal statements of the sample as colloquial scales to determine the weight of criteria and sub-criteria.(7.5,10,10) (5,7.5,10)(2,5,5,7) (0,2.5,5)(0,0,2.5)Triangular fuzzy number To weigh the criteria, the geometrical mean of the questionnaires obtained from the triangular fuzzy matrix of paired comparisons and the aggregation matrix of the experts' opinion were obtained (Table 3).In the following paragraphs, the value of fuzzy compound expansion of each of the criteria is computed, and then fuzzy feasibility degree for each possible paired state is computed (Table 4).Also, minimum feasibility degree of each of the criteria relative to other criteria is obtained to compute the weight vector of the four criteria (Table 5).To prioritize the sub-criteria of each of the four criteria, the above stages are performed; therefore, due to great size of computations, each of the sub-criteria is presented as shown in the following table:

Discussion
The quality of medical services highly influences the patients' decision to select their therapeutic destination.Appropriate medical services and facilities and provincial hospitals also can be introduced as one tourism targets for various patients around the world.
After 1995 and after the development of health and care units and the increase in people's access to services, the quality of services in certain dimensions has been considered as one of the important priorities and placed in the agenda of provinces.Executing various designs and pilots in the country, the basic healthcare facilities have been strengthened.However, there are still many deficits in facilities and equipment appropriate with modern technologies and global standards.Modifying these items is necessary to attract health tourists to Iran from various points of the world.The reputation of successful Iranian physicians in various points of the world and, especially in Arabic countries has made patients hospitalizing in these countries highly need Iranian doctors.
Frequent travels to Shiraz for such surgeries confirms this claim.The need for nurses with good knowledge of Arabic languages is obvious since most of patients come from Arab countries.However, given the official statistics and due to the fact that English language is their second language, it will not cause any serious problem due to use of nurses with good knowledge of English.Hospital managers of provinces can increase patients' satisfaction level through training hospital personnel about how to behave with patients as well as through considering welfare facilities for companions of non-native patients such as discounting, shortening residence time, providing services of coordination, travel, residence, transfer, and visit for patients and their companions.It is also suggested to perform some activities regarding establishing marketing offices in target markets, organizing informative travels for journalists in the province, supplying the insurance of medical tourism events and making a brand for a province in the area of therapy.Previously conducted studies have revealed that the presence of welfare and tourism facilities for patients' companions, in addition to medical facilities, is highly important.It is so important that in the article Tourism management health tourism attractions have been mentioned in some places under the name of hotel and shelter.This confirms the attraction of medical-tourism phenomenon, which indicates that a calm environment and tourism-recreational facilities are two necessary and adequate conditions to attract medical tourists to hospitals.Accordingly, recreational facilities for passing the recovery period are one of the most important factors for attracting tourist.In the present study, it was observed that welcoming patients and their companions from the arrival time and during the travel was a an important issue for such tourists.
Some recommendations are presented for further studies: 1. Existing health tourism capacities and potentials in Iran

2.
To what extent sub-indices of each health tourism development barrier in Iran are important?3. What are the most important cities of Iran in terms of health tourism development barriers?


Unreasonable cost of therapy  Not providing drug in accordance with universal prices  Arbitrary determination of medical tariffs by doctors  Not offering insurance to health tourists Quality:  Low-quality therapy  Personnel's lack of sufficient knowledge  Lack of friendly and polite behavior with patient by hospital personnel  Lack of welfare facilities such as residential complexes for patient companions Accessibility: Lack of easy access to medical centers  Lack of kitchens equipped with menu  Lack of interpreters with good command of English or target language  Lack of desirable and broad air travel  Lack of possibility of international communications for patients (telephone and internet) Proper time:  Not investigating hospitalization affairs in the shortest time possible  Not responding to electronic demands in the shortest time possible  Not prioritizing patient admission based on acuteness of disease  Not performing therapeutic stages in proper time

2.
Economy and trade from the perspective of health tourism 3. The barrier and strategies for the development and optimization of health tourism 4. The status of health tourism in Iran in comparison to international standards respect to the related literature and the opinions of the experts, the factors contributing to measurement of each of these indices in medical tourism development are as follows: Cross-sectoral indices related to the policy maker entity:1.The presence of rich, policy maker, organizer, and supervisor cross-sectoral entity

Table 1 .
Colloquial scales to determine the weight of criteria and sub-criteriaTable2shows colloquial scales to prioritize health tourism cities in terms of the presence of health tourism development barriers.

Table 2 .
Fuzzy number spectrum and linguistic scale to prioritize health tourism cities in terms of the presence of health tourism development barriers

Table 3 .
Aggregation matrix of the experts' opinion

Table 4 .
Weight vector of the four criteria

Table 5 .
The final weights of each of the indices Among the barriers, quality has the highest importance and proper time has the lowest importance, and among the sub-criteria, low-quality therapy demonstrates the highest importance (weight).Table6shows normalized aggregation matrix of the experts' opinions which has been used to prioritize the cities in terms of health tourism barriers.

Table 6 .
Normalized fuzzy aggregation matrix of the experts' opinionsThe values of Ri and Si are as follows:

Table 7 .
The values of Ri and Si