Qualitative Examination of Health Tourism and its Challenges

Introduction: Health tourism refers to travel for the use of services that improve or promote the physical or psychological health of an individual in a location apart from their place of residence lasting over 24 hours. Health tourism provides a sizeable share of revenues derived from the health sector in some countries. The high potential for health tourism in Iran, especially in the city of Mashhad, the need to establish a groundwork for health tourism in Iran that cannot be overemphasized. Because the transfer of knowledge and theoretical and practical synthesis are underlying concerns, this study examined how health tourism knowledge is transferred and applied from the perspective of health tourism officials and academics. Methods: This study adopted a qualitative approach based on grounded theory. Data collection was conducted through purposeful sampling using in-depth and semi-structured individual interviews. The conversations were recorded and then transcribed verbatim and finally analyzed using Strauss and Corbin’s coding paradigm and constant comparative analysis. Results: The results of interviews with 16 participants from among hospital managers, university professors and tourism and health insurance managers yielded 100 initial codes, out of which 60 conceptual labels or preliminary codes for broader concepts were extracted after repeated modification to reach conceptual density. Conclusion: Three categories having several subcategories were derived from the responses of participants: the challenges and benefits of health tourism, human interaction and communication and the impact of international standards.


Introduction
The leading Asian destinations for individuals seeking specialized medical care from other countries are Malaysia, India, Singapore, Thailand and the Philippines. Long waiting lists for medical procedures in Canada and the United Kingdom, rising costs, lack of insurance coverage, unfamiliarity with the health systems of the destination country and illegality of medical procedures such as kidney transplants in certain countries have prompted patients travel to other countries for medical care. Another factor motivating health tourism in Europe is access to efficient dental services. Many of the more than 47 million Americans without insurance coverage travel to India and Mexico to access efficient services. 1 It is commonly acknowledged that health tourism provides hospitals with a host of opportunities to offer services to patients from other countries. 2 Industrialization in many parts of the world has engendered the need for diverse communities, among which healthcare is of paramount importance. Countries have sought to benefit from this national opportunity by the promotion of medical tourism. 3,4 Tourism is a growth sector in the global economy and its effects reach beyond the economic and business aspects. With increased popular demand for travel and tourism and the prominent role played by the tourism industry, nations have attempted to tap this potential in line with socioeconomic development and infrastructural growth. The race between countries, especially developing countries in Asia, to attract health tourists has intensified. 5,6 Medical tourism is a legacy of health tourism. People have traveled in pursuit of medical services or health promotion for eons. 7 Health tourism is defined by the World Health Organization (WHO) as using services that improve physical or psychological health with the help of mineral water springs, climatic conditions or medical intervention in an area outside one's place of residence for more than 24 hours and less than one year. Most researchers integrate the terms medical tourism and health tourism and some use these terms interchangeably; therefore, it is important to distinguish between these concepts. 8 One definition describes tourists as those travel outside their living environment and stay there for least 24 hours. Travelers who do not meet the "24-hour" criteria are known as simply as visitors. 9 About half of studies related to health have been conducted in Europe and about one-third in Asia. Medical tourist arrivals in the Asian countries of Thailand, India and Singapore surpassed 10 million people by 2015, meaning that these countries control an estimated 80% of the world market. The medical tourism supply chain in Asia has been the subject of growing attention and is a key socioeconomic factor in most Asian countries. 10 One responsibility of the Ministry of Health and Medical Education and other participants in the health sector according to the 20-year vision protocol of Iran for 2025 is to establish health spas and centers and increase the export of medical services. Iran must focus more attention on this important economic sphere. Iran, with its huge potential and advantages for health tourism that include low cost, high quality health services, renowned experts and abundant natural attractions is determined to capitalize on this advantage. 11 The unique geographical situation and diversity of natural phenomena are but a few reasons contributing to Iran's position as ranking fifth in terms of natural diversity. 12 The diverse range of medical specialties and specialized medical centers have attracted patients from neighboring countries and the region to access health care services in Iran. This provides an apt opportunity and fertile ground for the development of the health tourism industry. The current study explored the health tourism industry and how to transfer and apply health tourism knowledge from the perspectives of university professors and health officials.

Methods
This qualitative research was based on grounded theory (2008). Data was collected through in-depth and semistructured interviews during purposeful sampling. Theoretical sampling based on variable extraction and theory formation was utilized. The number of interviews varied from one to two, each lasting from 30 minutes to two hours. Participants expressed their perceptions, experiences and views on the transfer of knowledge to the domain of health tourism until data saturation was achieved. Conversations were recorded and transcribed verbatim and then analyzed using Strauss and Corbin's paradigm coding and comparative analysis.
The validity and acceptability of data was evaluated using respondent validation. To compare the interpretation of the researcher with the actual meaning intended by the interviewee responses, their explanatory comments were sought. Another strategy adopted for assessing the reliability of data was evaluation by experts. To this end, three colleagues and a supervisor experienced in the field of qualitative research were asked to assess the various aspects of the study. The researchers attempted to provide full and transparent information, so the reader could attain proper understanding and transfer of knowledge.

Results
The participants were 16 hospital administrators, university professors and health tourism and insurance managers. Based on the research data, 100 initial codes were identified out of which 60 conceptual labels or preliminary codes for broader concepts were extracted after repeated modifications to reach conceptual density. Four themes were derived from the responses of the participants and were presented in three major categories with several subcategories: challenges and benefits of health tourism, human interaction and communication and the impact of international standards (Table 1).

Benefits and Importance of Health Tourism
The establishment and protection of health is a global issue that has occupied administrators across the world. The specialized services and logistical support to health centers is an important economic issue that affects all individuals in a society. The expense of health services in some countries has motivated people to seek medical services in other countries. As such, health system decision-makers, must consider the benefits of health tourism on the existing health services and focus on planning for the health tourism sector. If this ideal is realized, it can contribute to national development and the tourism industry from the inflow of foreign exchange and can contribute to an economic boom. In addition, the exchange of information and communication between cultures can lay the foundation of attitude change and contribute to the establishment of peace and friendship between nations.

Challenges of Health Tourism
The transfer of knowledge to health tourism is hampered by the nature of activities in the domain of health tourism related to recipient services and some associated with the health system of a country. One important factor that directly affects recipients of services is the absence of accurate and reliable advertising. The lack of an international organization to monitor international healthcare means that a country should provide reliable and trustworthy information about services.
Another factor that can directly influence recipients of services is related to insurance support. Unfortunately many countries do not offer full insurance coverage. Additional problems affecting a nation's health system is the lack of marketing services, political instability between countries, the absence of specialists, problems related to IT infrastructure; the resolution of each requires the adoption of appropriate solutions. One way to resolve these issues is to develop a global policy regarding insurance coverage and for the planning and development of political strategies to increase interaction and facilitate the travel of individuals.

International Standards
One challenge of health tourism that merits a specific category is the lack of international standards for health care. Disregard for or the absence of international standards for the provision of health services make it difficult for individuals to select suitable health care centers. It has been shown that adherence to international standards can foster the trust of potential health tourists in the selection of appropriate centers and make the legal system in charge of handling patient affairs more transparent.

Human Communication and Interaction
Experts offered diverse views on this subject. Some posited that individuals working in health centers should possess qualities such as patience, compassion, honesty and accountability and being accomplished in their professions and should be proficient in English as the international language. Others maintain that these features are not inherent to human interaction. Communications skills can taught and acquired and enforced by regulations that require all employees to satisfy the requirements of clients. All the issues discussed, whether related to the health system or recipients of services, can impede the transfer and application of health tourism knowledge.

Discussion
The expert opinions about how to apply and transfer health tourism knowledge fall into four areas: benefits of health tourism, health tourism challenges, international standards and human communication and interaction. Each was further divided into subcategories. Those for the benefits of health tourism were national development, economic boom and changes in national attitude. Those for challenges of health tourism were absence of advertising and marketing, lack of insurance coverage, political instability, scarcity of specialized forces, lack of marketing, lack of international standards for health centers, inability of medical centers to provide services and lack of IT infrastructure. Those for the existence of international standards were psychological comfort, quality assurance and integration of services. Those for human communications and interaction were personal characteristics of staff and appropriate communication with patients based on their culture and language. The findings of the present study are consistent with the results of a previous analysis of the health tourism market and its implication for the hotel industry with an emphasis on quality management and target markets, pricing, communication, distribution and collaboration of hotels, spa resorts, tourist associations, insurance companies and tourism and health policy makers. 13 A study on international accreditation of outpatient surgery centers and health tourism discussed the effects of international accreditation and standards on health tourism and covered issues like reduction of health tourism risks and provision of safe and high-quality services to the patients. These authors examined the challenges to insurance coverage for medical procedures, waiting lists and the cost of treatment. 14 The results were that long waiting lists, high costs, lack of insurance coverage, poor health care services, 1 illegality of some medical procedures, 1,15,16 lack of modern medical equipment and specialized personnel and long distance to travel for treatment are the main barriers to health tourism. Moreover, health tourism is plagued with issues during treatment such as weak face-to-face patient-doctor interaction before and after surgery, especially in emergency cases such as venous thrombosis, acute pulmonary edema, impaired consciousness, dehydration, and fatigue, limited patient-doctor interaction before surgery, infection and language barriers between patients and medical staff. 17

Conclusion
Despite the great potential and benefits of medical tourism in Iran, many challenges remain in this field. These include lack of advertising and marketing, absence of insurance coverage, political instability, lack of medical expertise and proper marketing, disregard for international standards, inability of medical centers to provide services and lack of IT infrastructure that adversely affect a desirable position for Iran in health tourism industry.
Iran could play a more prominent role in this market through greater investment on human interaction and communication, implementation of international standards and further efforts to identify and overcome challenges. The present research was a qualitative study with a limited sample size which was chosen purposefully. Although attempts were made to select samples from heath tourism-related professions, the views of the patients as the user of this system were not taken into consideration.

Authors Contributions
All authors contributed equally to the preparation of this paper.