Stakeholders' analysis of the medical tourism industry: development strategies in Isfahan.

INTRODUCTION: Policy makers and decision makers must identify the stakeholders in medical tourism, who will be affected by and/or affect this industry, and determine their status for partnership. The aim of this study was to identify the main stakeholders in Isfahan's medical tourism, analyze them, and provide strategies for developing this industry.
MATERIALS AND METHODS: A qualitative study was conducted in 2011. At first, the key stakeholders in medical tourism were identified in accordance with the experts' idea and literature review. Then we interviewed the key stakeholders. Data analysis was conducted using the stakeholders' analyses, which helped in developing strategies.
RESULTS: The result showed that the key stakeholders were made up of nine groups. They included the provincial governance of Isfahan, the Cultural Heritage and Tourism Organization of Isfahan, the Chamber of Commerce, the Medical Council, the Isfahan University of Medical Sciences, health service providers, tourism services providers, investors, and the Tosea Saderat Bank. The rate of knowledge of the Cultural Heritage and Tourism Organization of Isfahan, clinic and international relationship of Isfahan University of Medical Sciences from government policy about medical tourism were very much. Private Hospitals, the Medical Council, investors, and the University of Medical Sciences had great power. Private hospitals, clinics, the Cultural Heritage and Tourism Organization of Isfahan, and the University of Medical Sciences were in the supporter position. The effected strategies were the included strategies, focused on increasing power; increasing support, and on maintaining the position.
CONCLUSION: There are different stakeholders in the medical tourism industry. Thus, policy makers can plan, make a policy and decision, and use effective strategies to develop medical tourism by designing a medical tourism stakeholders' network, a medical tourism provincial council, and clarify the roles and responsibilities of stakeholders.

INTRODUCTION

Medical tourism – patients traveling to foreign countries for medical procedures – is an emerging phenomenon in the healthcare industry.[123] There are major reasons that cause people to get health care with international traveling including: Long waiting lists in developed countries, low cost in developing countries, development of intermediary companies between patients and hospital networks, and finally advanced technology that has emerged, with new health services.[2456]

In the past decade, medical tourism has grown in a number of Asian countries, such as India, Singapore, and Thailand,[478] and this practice has been the subject of increasing interest.[9] In Thailand, major private hospitals advertise their services in various media including newspapers, TV channels, internet, brochures, and tourist publications.[10]

The potential benefits of the medical tourism industry have been proposed by advocates. Medical tourism as a progressive economic strategy is a rapidly growing, multibillion dollar global industry, which increases income in the destination countries. Proponents argue that medical tourism helps to keep specialists in their own countries rather than them immigrating to foreign countries, with a reverse brain drain. Besides, medical tourism might help improve healthcare services and lead to more employment, help in improving the infrastructure, technology, and education, in order to attract more tourists.[111213]

Iran has some strength for medical tourism, such as, low-cost services, appropriate facilities, and experienced physicians. There are good opportunities in international markets for health services.[14] In this regard, the Ministry of Health has authorized a rule called, ‘terms and conditions for health tourist welcoming medical centers’.[815] Nevertheless, Iran is facing critical challenges, such as, poor relations between the medical tourism stakeholders.

Byrd (2007) stated that: “for sustainable tourism development to be successful, stakeholders must be involved in the process”.[16] Stakeholders means any individual, group, or institution, who potentially affects or would be affected by project activities and has something to gain or lose if conditions change or stay the same.[17] Stakeholders are all those who need to be considered in achieving project goals and whose participation and support are crucial to its success.[18] Studies indicate that intensifying the relationship between tourism companies themselves and between them and the policy makers is very important. Besides, it appears that public sector stakeholders play greater roles in both the management and marketing activities than the private sector, as they have a much higher position in the scale of preference.[19]

Given that joint strategy and shared objectives for various sectors of medical tourism, in order to facilitate better coordination between the concerned players – the Ministry of Health and Department of Tourism – are essential for medical tourism development,[20] identifying other key stakeholders, who should be encouraged to participate, and their situation in medical tourism is necessary.

Isfahan is one of the greatest cities in Iran, not only for its population and industries, but also for its cultural heritage and medical capacities. Therefore, this study aims to conduct a stakeholder analysis of medical tourism in Isfahan city, to provide appropriate strategies and approaches for stakeholder engagement.

MATERIALS AND METHODS

This is an applied and descriptive study, which had performed a qualitative research method in 2011. For selecting the sample, first, the researchers identified all the actors who could have an interest in the medical tourism policy, including actors outside the health sector, who could affect or be affected by the policy. In addition, researchers used on-site observations and measurements to collect complementary information. Then a list of all the possible stakeholders was developed. In order to collect information related to identify the key stakeholders was interviewed to medical tourism researchers and experts who know this policy.

In the second stage, the research participants were stakeholders who were chosen in the earlier stages, including, representatives from the Isfahan University of Medical Sciences, Administration of Cultural Heritage and Tourism of Isfahan, Province of Isfahan, Chamber of Commerce, State Medical Council, Health Service Providers (Hospitals and Clinics), Tourism Services Providers (Tour Operators and Tourism Companies), Investors, Tosea Saderat Bank. For selecting participants the snowball method was used, as one of the purposeful sampling method. Based on this type of sampling each of the participants could represent the next options were to participate in the discussion.

The semi-structured questionnaire was developed for the second stage (definitions of stakeholder characteristics), to interview the stakeholders. In the first part of the questionnaire, the stakeholders were asked about their knowledge of the medical tourism policy. Stakeholders were asked to circle their knowledge on a five-point Likert-type scale (‘very low’ to ‘very much’). In the second part of the questionnaire, the stakeholders were asked for their positions in medical tourism. The position of each stakeholder was established by:

Information directly reported by the stakeholder in the interviews, where they were asked to circle their position on a five-point Likert-type scale (strong Supporter (S), Moderate supporter (MS), Neutral (N), Moderate Opponent (MO), Opponent (O)).

Indirect information was gathered through other stakeholders and secondary information was indicated as a five-option continuum ranging from Supporter (S) to Opponent (O).

Then, any difference between the position that was self-reported and the position that was perceived by others was reconciled. Differences were resolved in the following manner:

When the stakeholder stated that he or she was against the policy, this was assumed to be accurate information, albeit subjective, because there was little incentive for the stakeholder to misrepresent his/her position. For moderate opponents (MO) or opponents (O), self-reporting determined the stakeholder's final position.

In the case of a self-reported neutral or supportive stakeholder, it was important to cross-reference the opinions of others, because the stakeholder could have an incentive to misrepresent his or her position.

When a discrepancy existed between the stakeholders’ self-reported position and that perceived by others, the researchers considered the relative weight of the available information.

Finally, the final position of the stakeholder was indicated as a five-option continuum ranging from Supporter (S) to Opponent (O) on the policy.

The third part of the questionnaire was about their power. The power index was derived from analyzing the two resource columns in the stakeholder's table: Their resources and ability to use them, which resulted in a power index, was indicated as a five-option continuum, ranging from ‘little power’ to ‘high power’.

Once the interview was completed, the information was analyzed by comparing the information and developing conclusions about the stakeholders’ relative power, knowledge, and position, with regard to the policy (Stakeholder table).

Finally, the researchers developed strategies to develop medical tourism, based on the results. The strategies focused on:

Maintaining the support of those stakeholders who were supporters

Increasing the power of the supporters

Converting the opponents and neutral stakeholders into supporters

Weakening the power of the opponents.

RESULTS

The possible stakeholders (potential stakeholders) in medical tourism were determined based on literature and document review. Then, from among them, the key stakeholder of this industry, in Isfahan city, was identified, by interviewing the experts of medical tourism. The key stakeholders were nine groups of organizations and people with an important role in medical tourism. The list of the possible and key stakeholders is shown in Table 1.

Table 1

Possible and key stakeholders in medical tourism in Isfahan city

In the second stage, stakeholders’ characteristics, including their position, rate of knowledge. and power were determined based on an interview with each of them [Table 2].

Table 2

Stakeholders’ analysis of medical tourism about their characteristics in the industry

As shown in Table 2, according to the private hospital and other stakeholders’ comments, the private hospital was a strong supporter in its final position, with low knowledge and high power. According to the interview with the private hospital, the own hospital and other stakeholders evaluated the position of the hospital as a strong supporter. Thus, the final position of the private hospital was entirely as a supporter. From the aspect of the amount of knowledge, the private hospital evaluated its awareness of the government's plan in the field of medical tourism as being low. Furthermore, from the aspect of the private hospital's power, considering the interviews, and the private hospital's opinion, there were many resources, and the most important among them was human. Moreover, the ability of the hospital to use and transfer the resources was approximately high, and in conclusion, its power in the field of medical tourism was evaluated as being at an approximately high level.

Regarding the clinics, according the results of Table 2, its final position was as the part of a strong supporter, with high knowledge and moderate power. So, the clinics’ and other organizations’ opinions were the same as the supporter position of the clinic. According to an interview with the manager of the mentioned clinic, their awareness of the medical tourism plan was very high. In addition, based on the interviews done, the resources of the clinic, including human, physical, and equipment resources, has been of a moderate amount, and thus the power of the clinic was also moderate in the field of medical tourism.

Regarding the public hospital, the final position of the hospital was in the part of a moderate supporter, with high awareness and moderate power. It was from the opinion of the public hospital itself that its position was as a strong supporter. In regard to other organizations’ opinion about the public hospital position, three participants were totally agreeable, one participant approximately agreed, and one of the participants was nearly opposed. Also, with regard to power, according to the interviews done and the hospital's opinion, the amount of its human, physical, and technology resources were very high, but in the aspects of financial resources, regulation, and legislation it was very low. In addition, their ability to resource transformation was very low; so, the power of the public hospital was evaluated as being mediate.

Regarding the Tosea Saderat bank, the final position of the bank, based on its own opinion in addition to the ideas of other organizations, was evaluated as a moderate supporter–neutral. As the bank evaluated itself as a moderate supporter and two other organizations evaluated it as neutral. With regard to the awareness of the bank of the medical tourism plan, its awareness was at the mediate level, based on the interview conducted with the bank manager. Also based on the opinion of the bank, the bank resources had been in the financial field, including Rial and other currencies, which was of a mediate amount and very low in the ability of resource transfer. Therefore, according to this, the Bank power in the field of medical tourism was evaluated to be at a moderate level.

With respect to the University of Medical Sciences, the Health Deputy and International Relationships Department were in the position of strong supporters, with high power. In addition to the rate of knowledge, after the interview, the Health Deputy was moderately aware of and the International Relationship Department was fully aware of the government's plan. On the self-evaluation of the Health Deputy and International Relationship added to the opinions of other organizations, the strong supporter position was mentioned for the University of Medical Sciences. On the other side, regarding the interviews, the University resources were very high, including human, equipments, and budget resources. The ability of using of resource was at the moderate level, and in conclusion, the University power in the medical tourism industry was evaluated to be at a high level.

With regard to the Cultural Heritage and Tourism Organization, its final position according to its opinion and other organization's ideas, was at the strong supporter position. According to the interview done with this organization, the extent of their awareness of the government's plan in the field of medical tourism was high. Also, the amount of resources of the Cultural Heritage and Tourism Organization was high and it was facilitated to hotels, travel agencies, and foreign tour operators. The ability to transfer and use the resources in the Cultural Heritage and Tourism Organization is low, so its power is evaluated as being at the mediate level.

Regarding the Chamber of Commerce, according to its opinion and other organization's ideas, the final position of this organization was at the neutral level, as the chamber of commerce evaluated its position as a moderate supporter and one of the participants evaluated it as neutral. Based on the interview with the Chamber of Commerce manager, it was seen that their awareness of the government plan was at a mediate level. In addition, the amount of chamber resources was mediate and it facilitated human resources and people's membership, its ability to use the resources was very low. Thus, the power was evaluated as being low.

With regard to the Medical Council, according to the opinions of the organization and also what other organizations announced, the position of the Medical council was evaluated as moderate supporter–neutral. It was while that according to the self-evaluation, the medical council announced its position as agree and supporter and one of the other participants evaluated it as moderate supporter–neutral. Based on the interview with the Medical Council, their awareness of the government plan in the field of medical tourism was at the mediate level. On the other hand, the amount of their resources was high and they facilitated human resources; while the Medical Council had low ability for resource transformation and using; in conclusion, the power of the Medical Council in Medical Tourism Industry was evaluated to be high.

Regarding the Investor, he had a neutral position with high power and moderate awareness. Considering the position, the self-evaluation of the investor showed it moderately agreed, while the opinion of two other stakeholders was neutral. Also from the side of the power index, the amount of investor's resources was high, and it facilitated financial and reputation resources in different organizations, so the conclusion showed that the power of the investor in the Medical Tourism Industry was approximately high.

According to the provincial governance of Isfahan, it has been in the strong supporter position according to its opinion and the ideas of other organizations. Based on the interview with the provincial governance, their awareness of the government plan of medical tourism was evaluated as being high. The amount of resources was low in the provincial governance, but their ability to use and transfer resources was high and it facilitated the special budget for a research map, tourism committee, and was also supported by the investor. Therefore, the power of the provincial governance in medical tourism was evaluated to be at a moderate level.

In the third stage, according to the characteristics of the stakeholders (power and position), the related strategies are divided into strategies focusing on maintaining the support position of the stakeholders, strategies focusing on the power increase of the supporter, and strategies focusing on converting the neutral stakeholders into supporters. [Table 3].

Table 3

Strategies of medical tourism development based on stakeholders’ characteristics

DISCUSSION

This study attempts to present the strategies for medical tourism development in Isfahan, with regard to stakeholder assessment and management. This attempt is critical in helping to understand the stakeholders’ role in successful medical tourism. Results showed that the medical tourism stakeholders in Isfahan were nine groups including, the Provincial Governance of Isfahan, Cultural Heritage and Tourism Organization of Isfahan, Chamber of Commerce, State Medical Council, Isfahan University of Medical Sciences, Health Services Providers, Tourism Services Providers, Investors, Tosea Saderat Bank.

Jabbari (2007) has divided the actors of medical tourism into three groups – supportive groups, heath providers, tourism services providers.[21] The stakeholders of medical tourism in India (Prasad 2008) were the Indian Government, including Ministry of Health, Ministry of External Affairs, and Ministry of Tourism, and the State Governments of different states, the corporate run health institutions, the financial institutions like Tourism Finance Corporation of India, and the Medical Council of India, the Indian Healthcare Federation and different industry chambers.[22] However, in the Jabbari and Prasad studies, the medical tourism industry in all countries was evaluated, while in our research medical tourism was studied as a regional industry and conducted in Isfahan city. The operators were one of the stockholders in the Cabalerro research.[23] This outcome was proven in the current study and generated the same result. Semercioz (2008)[24] stated that some stakeholers for the Turkey Tourism Industry were tour operators and the Chamber of Commerce, which was similar to the current study.

In this study, the University of Medical Sciences, Clinics, Private Hospitals, and the Administration of Cultural Heritage and Tourism were strong supporter stakeholders of Medical Tourism. Being in a position of maintaining the strategy is a suitable approach for these stakeholders. In the Semercioz research, all of the identified tourism stakeholders were in the support position and none of stakeholders were a potential threat. This result was similar to the current study. Also Sheehan (2005)[25] stated that some stakeholders had been potential to threaten with the Destination management, an organization that was different from our study.

When comparing the rate of the stakeholders’ knowledge about the government plan in medical tourism, different knowledge rates were determined. For example, International Relationships, Administration of Cultural Heritage and Tourism, and Clinics had very high knowledge; Private Hospitals had low knowledge; and Investor, Chamber of Commerce, Bank, and Medical Council had moderate knowledge. Additionally, the Provincial Governance of Isfahan, Health Deputy, and the Public Hospital had high knowledge. These findings reflect poor information on the government plan in medical tourism.

Another aspect of medical tourism stakeholders was the power index. The findings showed that the Chamber of Commerce, Administration of Cultural Heritage and Tourism, Provincial Governance of Isfahan, Clinics, Public Hospitals, and the Bank had moderate power and Private Hospital, Medical Council, University of Medical Sciences, and Investors had high power in medical tourism industry. Therefore, paying attention to stakeholder power in addition to position was an important indicator for developing strategies on medical tourism.

CONCLUSION

Medical tourism is a lucrative industry, has significant impacts on the healthcare structure and economic growth. Applying developmental strategies to this industry, in order to achieve developmental programs in Iran, is essential. One of the appropriate approaches to succeed is establishment and a suitable network among the medical tourism stakeholders. Designing a stakeholders’ network and specifying their roles in the planning, policy- and decision-making, stewardship, and implementation is one of the options that is available.

The results represented that the Medical Tourism Industry of Isfahan city has many stakeholders. Even as some of the stakeholders are in the neutral position, others have moderate power. Therefore, attention to these characteristics when planning a development is necessary. In addition, it is vital to form a provincial council of medical tourism, assign the main responsibilities, and delegate the necessary authority to stakeholders.

Following are some suggestions for developing the Medical Tourism Industry in Isfahan based on the mentioned strategies:

Strategies for converting the moderate and neutral stakeholders into supporters:

Membership of stakeholders in the provincial council of medical tourism (the strategy related to all stakeholders)

Legislation transparent rules for managing medical errors and adverse side-effects of drugs (the strategy related to medical council)

Providing advocate services for investors (the strategy related to investors)

Providing information about guidelines of medical tourism (the strategy related to bank, Chamber of Commerce, Medical Council, Private Hospital, and Investors).

The strategies for increasing supporter stakeholders’ powers:

Simplification of using space and facilitation for non-government section (the strategy related to clinics)

Membership of stakeholders in provincial council of medical tourism (the strategy related to all stakeholders)

Delegating necessary authorities to provinces for adding flexibility to medical tourism planning and promoting efficiency and effectiveness (the strategy related to provincial governance)

Delegating authorities to the Chamber of Commerce as a responsible organization for developing advertising programs and investors education, according to the organization's mission (the strategy related to Chamber of Commerce).

The strategies for maintaining of supporter stakeholders’ position:

Delegating necessary authorities to the University of Medical Sciences to develop flexible programs for medical tourism, to promote efficiency and effectiveness (the strategy related to University of Medical Sciences)

Simplification of using space and facilities for non-government section (the strategy related to private hospital).