1. Background
The concept of entrepreneurship was first invented in the French language (1), adopted from the French term “Entreprendre”, meaning “intervener and mediator” or from the English term “to undertake” (2), which was translated to “entrepreneurship” in English by Stewart Male in 1848. In the Persian language, this term was first proposed as “the employer” and then “entrepreneurship”, which is defined as an individual who undertakes a task.
Since the 1980s, the changes in the values and tendencies of societies and sociological changes in many developed countries led to the emergence of a wave of small businesses and self-employed individuals, which in turn prompted the studies regarding the subject of entrepreneurship from numerous perspectives and by different scientific courses, such as economy, management, sociology, psychology, medicine, and health (3). Entrepreneurship is considered to be a process of exploring and benefitting from opportunities for the creation of value in economic, cultural, social, and healthcare sections as the basis of sustainable development (4).
According to Dracker, although several years have passed since the introduction of the concept of entrepreneurship, the recent environmental conditions have resulted in a revolution in entrepreneurship (5). According to the viewpoint of Schumpeter, which denotes that “entrepreneurship is a motor for development”, many countries in the world have come to believe that entrepreneurship plays a critical role in economic growth and development (6). As a result, numerous developed and developing countries have recognized the entrepreneurship growth of the tourism industry as an effective approach to the flourishing of their economy (7).
According to the Global Tourism Council (GTC), approximately 9% of the world’s gross domestic product is solidified directly or indirectly through the tourism industry, and about 255 million individuals are active in this industry (8). As the benefits of other industries have been on the decline, the tourism industry may be an appropriate approach as a new section for economic development (9). The number of international travels is predicted to increase dramatically in the second half of the century (10), and the tendency toward tourism entrepreneurship has also grown across the world (11).
Several studies and investigations have indicated that the tourism industry is a highly efficient industry in the world following oil and automotive industries (12). The tourism industry plays a pivotal role in improving employment in every community (13). Entrepreneurship development is attracting the attention of the researchers in the tourism industry, while the key requirement for growth and development in this industry is the use of new methods and techniques in various communities depending on their geographical area (14).
The development of tourism could result in the attraction of capital, which in turn improves other sections (15). Undoubtedly, the durability of any industry, particularly the tourism industry, depends on the recognition of the possible barriers and challenges. According to the World Travel and Tourism Council (WTTC), tourism is a complex economic sector, which significantly affects employment, the balance of payments, and socioeconomic development of various regions, while also participating in the creation of gross domestic products, thereby affecting the revenues of local budgets (16). This definition also has an economic aspect, which mainly points to its applicable policy (17).
Based on all the definitions of tourism presented before 1994, the global organization of tourism published a final definition in 1995 (18). Accordingly, tourism is defined as a set of activities that are carried out through traveling to other locations than the routine residence of individuals and staying for a minimum of one night and a maximum of one year. The mere goal of traveling is to spend leisure time without regard for occupation and attaining incomes. The tourism industry is divided into various sections. Medical and healthcare tourism is a sub-section of this industry, which has been expanding over time. According to the Global Bank, the third arena of capitalism in the world pertains to this type of tourism (19).
Health tourism is one of the fastest-growing clusters in the global economy. With the advent of technology and treatment patterns, the health sector is no longer merely providing care to the ill and is also the provider of beauty and wellbeing to those undergoing surgery. The rapid changes in technology and healthcare standards is the result of globalization, which has created a culture of consumption and availability to purchase services such as medical care in any destination (20). International travel is also increasing with the aim of acquiring health care based on the ease of access and cost-efficiency (21).
The World Health Organization (WHO) defines health tourism as international travel to receive health and medical services. In other words, it is a journey taking more than 24 hours and less than one year, which is carried out for disease prevention, treatment and/or convalescence (22). The number of health tourists has been reported to be on the rise, who are mostly from developing countries, seeking to improve their health abroad, especially in developed countries (23). According to the United Nations World Tourism Organization (UNTWO, 2019), the global medical tourism market was valued at USD 16,761 million in 2018 and is expected to grow to approximately USD 27,247.6 million by 2024 according to the report of Mordor Intelligence. In addition, the reports by VISA and Oxford Economics have denoted that approximately 11 million medical tourists create worth of USD 100 billion market value annually, which offers a huge market with the growth rate at 25% per year (24).
Today, a reverse phenomenon is observed in medical and healthcare tourism throughout the world, so that traveling to developing countries (e.g., India, Brazil, and Thailand) is increasing more noticeably compared to developed countries. Consequently, health tourists are seeking destinations where the costs of medical and health care are low and economical. However, this trend has created the opportunity for developing countries, including Iran, to develop an appropriate context for increased activity in this area by organizing the related infrastructures and facilities (25).
According to the dynamic capability theory, the ability of organizations to integrate the creation and reconfiguration of the internal and external organizational capabilities is aimed at responding to changing environments (26). Therefore, identifying the barriers in each industry is essential to the realization of the dynamic capability theory. The medical and health tourists in Iran are mainly from the Republic of Azerbaijan, Iraq, Turkmenistan, Afghanistan, Kuwait, Syria, Lebanon, Bahrain, and Turkey, and Iran progressed by 20% - 25% in the area of health tourism during the past decade (27).
2. Objectives
Currently, Kermanshah covers an area of 24,640 square kilometers and is considered to be the 17th wide province in Iran (1.5% of the total area of the country). Kermanshah has diverse tourist attractions, while the current status of these attractions remains dissatisfactory. Medicine and health care are important fields of tourism, which were investigated in the present study. Kermanshah has numerous advantages in terms of health tourism attraction owing to its geographical location (vicinity to Iraq country), diverse climate, expert physicians, and being the most developed western province in Iran; however, there are also some limitations in this regard. The present study aimed to identify the main barriers against the development of the medical and healthcare tourism industry in Kermanshah.
3. Methods
This explorative study was conducted with a mixed design. Targeted sampling was performed for the qualitative and quantitative variables using the snowball method. The methodology of the study had three sections, including qualitative analysis, interpretive structural model (ISM), and quantitative analysis. The first section of the study involved the qualitative approach, which was applied to detect the barriers affecting the entrepreneurship development of the medical and healthcare tourism industry in Kermanshah.
Data were collected via semi-structured interviews with 18 experts, and theoretical saturation was obtained by interviewing the last individual. Following that, the open and axial coding method was used to determine the primary and secondary agents. The validity of the hidings was assessed by five experts and skilled individuals, and the detected agents were confirmed again. In order to calculate the stability of the research, three interviews were conducted, and each was coded again by the investigator within two 15-day periods. The total number of the codes in both periods was 114, the number of the similarities between the codes was 45, and the number of the dissimilarities in both periods was 24. In addition, the stability of the conducted interviews was estimated at 78%, and since the percentage of stability was above 60%, the coding reliabilities were considered acceptable as well.
In order to collect the required data for the ISM method and DEMATEL, two eight-agent paired comparison questionnaires were designed, which consisted of 56 items for the interviewees. In the designed questionnaire, the experts were requested to determine the type of the considered agent in terms of effectiveness and interaction. Afterwards, eight axial factors were provided in the rows and columns of the table, and the respondents were requested to determine the type of the mutual relations between these factors by O, X, V, and A symbols.
In the third section of the research, the DEMATEL method was used, and a questionnaire was also codified. At this stage, the respondents were asked to determine the intensity of the impact the factors on each other in the quantitative form and based on the DEMATEL quintuplet spectrum. The questionnaire associated with the ISM section was distributed among 20 experts and skilled individuals in the field. Moreover, the DEMATEL questionnaire was provided to 12 experts, and the DEMATEL modeling was applied to determine their effectiveness. For the prioritization of the detected barriers against the entrepreneurship development of medical and healthcare tourism, the ISM method was applied, and the intensity of the quantitative correlations between the factors was assessed using the DEMATEL method. Both ISM and DEMATEL were simultaneously used since their combination is complementary, resulting in the comprehension of the correlations between the agents.
4. Results
In the qualitative section, eight major factors were detected as the entrepreneurship barriers in the medical and healthcare tourism of Kermanshah based on the conducted interviews and coding trends. The identified barriers included infrastructural barriers, marketing and advertisement barriers, human barriers, management barriers, governmental barriers, barriers in rules and regulations, cultural barriers against tourism development, and barriers in the cooperation of the private sector with the governmental sector (Appendix 1 in Supplementary File).
Considering that the investigation aimed to detect, prioritize, and determine the levels of the barriers against medical and healthcare tourism entrepreneurship, the ISM method proved effective in this regard, and the second section of the method was used to determine and assort the barriers against medical and healthcare tourism. To assess the correlations and determine the levels of the influential factors, eight axial factors regarding the effectiveness of health tourism entrepreneurship were initially evaluated, and a self-interacted ISM matrix was formed in order to examine the variable of the problems in some pairs. Correspondingly, the questionnaire was designed as Appendix 1 in Supplementary File) and provided to 20 academic experts, and 18 questionnaires were completed. Afterwards, the completed questionnaires were provided to a group consisting of four medical and health tourism experts, and the blanks that were common in the questionnaire were transferred to a new questionnaire by the group. The correlations were determined for the differences in the views and obtained based on the correlations observed in Appendix 1 in Supplementary File). In order to make the access matrix compatible, the initial access matrix was obtained, and the final access matrix had to be obtained by considering the transferability and compatibility in the correlations of the variables. Correspondingly, the following formulas represent the method used to determine the access matrix using the adjacency matrix:
Step 1: A + I
Step 2: M = (A + I)n
In the formulas above, A is the initial access matrix, I shows the identity matrix, and M represents the final access matrix. The operation of making the matrix exponential was performed based on Bolin rule with the following basis:
1 + 1 = 1 and 1 × 1 = 1
In order to determine the levels and prioritization of the variables, the components of the structure were classified into various levels with the aim of detecting their correlations, and the obtained levels are presented in Appendix 4 in Supplementary File). The DEMATEL method was used to quantify the interactions between the factors, in which a matrix was used to represent the direct and indirect correlations and level of effectiveness among the factors. In the DEMATEL method, with the assumption that n factors affected the considered system, a measurement system was established to measure the cause-and-effect correlations between the factors. The measurement levels were represented by five levels (0 - 4), in which level zero represented ineffectiveness, level one represented extremely low effectiveness, level two represented low effectiveness, level three showed high effectiveness, and level four indicated extremely high effectiveness. The correlations and levels of effectiveness among the factors were obtained based on the views of the experts in a square matrix of direct correlations between the factors. In this matrix, each xij element represented the effectiveness level of element i on element j. Appendix 4 in Supplementary File shows the matrix of the direct correlations between the influential factors in the medical and healthcare tourism entrepreneurship (see Appendix 1 in Supplementary File).
At the next stage, the matrix of the normalized direct correlations was obtained based on the normalization factor, which equaled the maximum of the maximum row sum and maximum column sum of the average matrix as determined by the following equation:
1 ≤ i ≤ k; 1 ≤ j ≤ k
At the following stage, the matrix of the direct and indirect correlations (T) was obtained using the following formula:
Finally, based on the variables and final access matrix extracted from the ISM and matrix of the direct and indirect correlations obtained from the DEMATEL method, the modeling and analysis of the interactions between the influential factors in the medical and healthcare tourism entrepreneurship were extracted using the DEMATEL and ISM methods. Based on the ISM method, the detected barriers were assorted in three levels, and the effects of each barrier were specified based on the DEMATEL method (Figure 1).
Figure 1.
Barriers in medical and healthcare tourism entrepreneurship in Kermanshah
5. Discussion
The present study aimed to identify the barriers against the medical and healthcare tourism entrepreneurship in Kermanshah and assess the levels of the factors and effectiveness of their interactions. Initially, a literature review of medical and health entrepreneurship was conducted, and numerous interviews were performed with the policymakers and activists in this field, and the obtained data from the qualitative interviews were collected.
The concepts and linguistic propositions obtained during the open coding and axial coding were assorted, and the influential factors in medical and healthcare tourism entrepreneurship were identified as well. Following that, the barriers were detected, and their levels were determined using the ISM method. The DEMATEL method was also applied to assess the correlations between the factors quantitatively, based on which the essential barriers affecting medical and healthcare tourism entrepreneurship were summed up as eight main factors. Based on a comparative study carried out along with other studies, some of these barriers were not observed in the previous research and were considered as the new outcomes of the present study. These factors included the cultural barriers in tourism development and barriers in the cooperation between the governmental and private sectors.
In a study by Azizi and Zahedi (2015), factors such as high costs, limited advertisements, and lack of human resources were reported to be the foremost barriers against health tourism in Yazd province (Iran). However, the effects of cultural barriers in tourism development were not observed in the mentioned study. In the current research, the cultural barriers against tourism development largely influenced the entrepreneurship development of health tourism in Kermanshah. In this regard, the findings of Hosseni and Asaadi (2013) indicated that perceived cultural differences were among the secondary influential factors in the communicative barriers in therapeutic tourism development in Iran. Furthermore, the findings reported by Saramad Research Institute (Iran) regarding the challenges of tourism in Iran indicated the lack of cooperation between the private and governmental sectors as a barrier against entrepreneurship, while the other barriers were not elaborated on.
In a research performed by Sharifi (2017) entitled “the detection and ranking of the barriers in medical tourism development in Guilan Province, Iran”, factors such as economic barriers, human resource barriers, and policymaking were reported to be foremost in this regard. Although some studies have been focused on health tourism, none of the mentioned factors have been identified, and there are no statements regarding the cultural components and cooperation between the private and governmental sectors. Only in some studies, these factors have been highlighted as secondary factors.
5.1. Implications and Recommendations
5.1.1. Policy Implications
Based on the findings of the current research, some recommendations have been proposed regarding the key influential factors in the health tourism industry in Kermanshah and other developing countries. The findings revealed eight factors that hindered health tourism entrepreneurship development. Some actionable implications have been listed below in order to address the main identified barriers.
Rules and regulations: By reforming the rules and regulations, the government could increase the cooperation of the private sector in the health tourism industry and facilitate the entrance and exit of foreign tourists. In addition, designing and developing appropriate approaches for the mutual acceptance of supplementary insurances in the target market countries may be a proper solution for international insurances.
Advertising and marketing: It is suggested that special attention be paid to the marketing and branding programs of tourist destinations in order to improve the image of the source facilities in the international markets. Furthermore, systematic marketing research should be conducted in this regard. By presenting a comprehensive communication marketing plan, all the private and public stakeholders would be involved, and continuous presence in international conferences and exhibitions to better introduce the health tourism potentials of the province should also be considered.
Culture: Although cultural changes require long-term planning, cultural-educational programs are considered to be appropriate solutions for cultural changes. Providing local and national media cultural programs could also support proper interactions with tourists. In addition, attention should be paid to the maintaining and promoting of cultural, religious, and dialectal affinity to effectively attract foreign health tourists.
Public-private sector cooperation: It is proposed that the Extra-Organizational Committees, which are composed of the representatives of active organizations, design a mechanism to strengthen coordination through the mastery of regulations and structural details. It should also be agreed that the Health Tourism Coordination Organizations enjoy stability, coherence, and legal obligations and be governed by a common goal. The representatives of the private sector are also members of the committee and are able to follow health tourism issues. The government, in cooperation with the private sector, should hold special congresses and events for the further coordination of the two sectors.
Infrastructures: With the construction of hospital hotels and providing easy access to exchange offices and banks, appropriate conditions will be provided for attracting health tourists. In addition to meeting global and international standards, healthcare providers must also exhibit the price of their services clearly on their websites, while also connecting their development infrastructures to the global network.
Management: A roadmap of health tourism in the province should be prepared with the cooperation of responsible and interested organizations, and the participation of all organizations in the preparation of this roadmap should be granted. The appointing of efficient professional managers in the health tourism sector is another issue that should be addressed in this regard. Monitoring the activities of agencies, transportation networks, and other active sectors in this area should also be considered. It is recommended that the role of the monitoring and control of these issues be assigned to the private sector.
Government: Governments are able to support health tourism in numerous ways. The government must plan a framework to support investment in this field. Given the international sanctions that have been imposed on Iran, we must communicate with the world through active diplomacy. Undoubtedly, interaction with the world (especially in developed countries) will have a direct and undeniable impact on the success of all the aspects of health tourism. Therefore, national macro policies should interact with other countries. Furthermore, the government must establish the necessary and sufficient facilities in the entry points of the country and provinces so as to have accurate information regarding the possible entry of infectious and contagious patients into the country.
Human Resources: Attention should be paid to the empowerment of active human resources in health tourism in the province, as well as proper interactions with foreign tourists and creating the proper conditions for the engagement of the most qualified individuals in these fields.
5.2. Conclusions
With globalization, medical and healthcare tourism has become a new and emerging international business, which is gradually gaining importance. As a result, numerous entrepreneurial opportunities have arisen to capitalize on the growth of this industry. According to the results of the study, the barriers against the medical and healthcare tourism entrepreneurship in Kermanshah interacted with each other on various levels in the form of a model. The most effective levels were levels III, II, and I (Figure 1). Level III encompassed barriers in rules and regulations, barriers in marketing and advertisement, cultural barriers in tourism development, and lack of cooperation between the private and governmental sectors. As is depicted in Figure 1, level III may be the foundation for levels II and I.
The results obtained from the matrix of the direct and indirect correlations based on the DEMATEL and ISM methods (Appendix 4 in Supplementary File) regarding the value of effectiveness have also been shown in the same figure for each factor at this level. In level II, infrastructural barriers significantly influenced medical and healthcare tourism entrepreneurship. In level I, human, governmental, and managerial barriers were considered foremost medical and health tourism entrepreneurship based on the ISM and DEMATEL methods. Figure 1 depicts the results obtained from the ISM and DEMATEL methods. The detection of the influential factors in all the levels contributed to the detection of the barriers against medical and health tourism entrepreneurship. In conclusion, attention must be paid to the importance of tourism in further investigations in this regard by considering the other aspects of entrepreneurship on various levels and in other sections.
