Identifying and Prioritizing Strategies for Developing Medical Tourism in the Social Security Organization of Iran: A SWOT-AHP Hybrid Approach

Background: The present study aimed to identify and prioritize strategies for medical tourism improvement in the Social Security Organization (SSO) of Iran. Methods: Using Delphi method in the first step, we identify strengths, weaknesses, opportunities and threats that Social Security Organization of Iran faces in medical tourism during 2017–2018. In the second step we interviewed 100 medical and tourism experts to identify proper strategies using SWOT method and finally priori-tize strategies through the Analytic Hierarchy Process (AHP) by using Expert Choice software. Results: The application of SWOT technique indicated that the dominant strategy for the Iranian SSO should be conservative. It should overcome its internal weaknesses and exploit its external opportunities. The Iranian Social Security Organization should arrange appropriate marketing in target countries, invest in international medical/hospital standards, boost the communicative competence of personnel in SSO hospitals and create multilingual web-based information to introduce the capabilities and costs of the hospitals. Conclusion: Since the SSO’s weaknesses are more prominent than its strengths, thus SSO should plan to reduce its weaknesses to boost medical tourism. For this purpose, SSO should design coherent plans for attract medical tourists to the organization’s hospitals, attempt to upgrade hospital and medical centers standards, train the medical staff regarding linguistic and communicative skills, and run a user-friendly website to introduce its medical capabilities.

of domestic resources to increase the national income (2). There has been a growing competition among different countries and particularly developing Asian countries to attract health tourists (3). The ease of seeking medical treatment and services overseas contributes to the globalization of the healthcare market (4). According to the calculations, the foreign currency inflow by a health tourist is three times as much as a typical tourist (5). Considering the health tourism as a low-cost and high-yield industry, different countries are interested in developing tourism with an emphasis on health sector (6). Concerning its advantages in the field of health tourism including low costs, high-quality services, competent physicians, and having abundant natural attractions, Iran aims to make use of this opportunity (7). Public infrastructure development strategy, human resources development strategy, information system and marketing development strategy, and product development strategy have been identified as the most important factors influencing the development of Iran's medical tourism industry (8,9). Numerous studies have been conducted to recognize effective factors on medical tourism industry in world. A package of effective strategies has been proposed to develop medical tourism in Turkey. This package includes increasing competitiveness in medical services' prices, easing the use of transportation and technological capabilities, promotion and marketing activities, increase in patients' satisfaction during the initial welcoming, treatments and hospitality, touristic activities and departures, and employment of qualified, well-trained and fluent in foreign language staff in host hospitals (10). A SWOT analysis of medical tourism sector in India showed that as per international patients' perspective, alternative treatment facilities like yoga have emerged out to be the biggest strength and cost of medical procedures which is comparatively lesser than developed countries are ranked as the second biggest strength (11).
The Social Security Organization (SSO) of Iran is the second largest provider of health services after the Ministry of Health and Medical Education. It covers more than 40 million of the population. This organization comprises 70 selfowned hospitals, 109 specialized specialist clinics, 93 general out-patient clinics, 83 specialized polyclinics and 6 Day clinics across the country. In recent years, SSO has suffered from imbalance in revenue and expense accounts (12). Encouraging medical tourism is one of the revenue-generating approaches for SSO, since it has various capabilities in the field of hospital and clinical services including skilled physicians, wellequipped and up-to-date medical centers. In addition, if SSO deals with medical tourism, the inflows of foreign currency will increase. This study aimed to examine the pre-requisites, necessities, strengths/weaknesses, opportunities/threats facing the organization in dealing with medical tourism. This research aimed to identify and prioritize strategies of medical tourism development in SSO of Iran using SWOT-AHP hybrid method. Particularly, this research will answer the following questions:  What are the internal/external factors affecting the development of medical tourism in Iranian Social Security Organization?  What are the strategies for the development of medical tourism in Iranian Social Security Organization?  What are the priorities of strategies for the development of medical tourism in Iranian Social Security Organization?

Materials and Methods
This research uses a combination of SWOT and AHP methods. In the following, these methods are introduced briefly.

SWOT Method
SWOT(Strengths-Weaknesses-Opportunities-Threats) technique is a tool for strategic planning used in many organizations to examine whether the goals are defined clearly or not, and whether all the relevant factors-positive or negative-are identified (13). The comparison of strengths, weaknesses, opportunities and threats offers the final matrix including appropriate strategies applicable to the current status of the organization. External opportunities/threats are the existing events and processes outside the organization (14).

AHP (Analytic Hierarchy Process) Technique
Thomas L. Saaty first introduced analytical Hierarchy Process in 1980 (15). This technique merges the experts' opinions and evaluations and then transforms the complex decision making into a simple hierarchical system. It makes use of the scale-based evaluations for examining relative importance of pairwise comparisons among criteria (16).

SWOT-AHP Hybrid Method
This method combines SWOT and AHP methods and constructs a matrix of strengths/weaknesses and opportunities/threats. This analysis is carried out in four steps as follows:  Step 1: The internal factors (strengths and weaknesses) and external factors (opportunities/threats) affecting development of medical tourism are identified using experts' opinions (Delphi Group), and SWOT matrix is formed.  Step 2: The scoring and ranking of internal/external factors are carried out using experts' opinions.  Step 3: To formulate and design the effective and appropriate strategy, SWOT matrix should be formed and following general strategies should be proposed: a. SO Strategy: Making use of strengths to enjoy external opportunities b. WO Strategy: Reducing internal weaknesses or improving ignored strengths to enjoy opportunities c. ST Strategy: Making use of internal strengths to reduce external threats d. WT Strategy: Reducing internal weaknesses to prevent external threats  Step 4: The strategies are prioritized using the AHP pairwise comparisons method. Materials of this research are provided by designing and completing questionnaires. In this research we arranged interviews with 3 statistical societies. The first one includes 10 experts in tourism and medicine scope that we call it focus group. In the first phase, this population was responsible for identifying strengths/weaknesses and opportunities/threats using Delphi method. The second statistical population consists of medical care managers acting in the headquarters and other regional offices, SSO health experts, managers and experts of Tourism Holding of Social Security Organization. The data was collected using 3 questionnaires: questionnaire No.1, distributed among members of the first statistical population (Focus Group), led to the identification of effective internal/external factors facing SSO about medical tourism. Questionnaire No.2 was designed according to the SWOT structure and was handed to 100 medical and tourism experts to define relative weights of weaknesses, strengths, opportunities and threats and to propose the appropriate strategies. Questionnaire No.3 was formed based on pairwise comparisons and Saaty scale (AHP) to prioritize the strategies defined in step 2 with the help of the decision-making group.

Findings of the first phase
The findings of the first phase of the research are summarized in Table 1. It reports Delphi group opinions and classifies internal/external factors facing SSO in the field of medical tourism.

Findings of the second phase
In order to identify the factors which are out of the control of SSO, a list of opportunities and threats, and strengths/weaknesses of the organization is offered in Tables 2 and 3. We have provided this using questionnaire No. 2 by asking the opinions of medical care managers/experts, and other experts of tourism and medical sectors. External factors evaluation matrix (EFE) is a strategic tool used to evaluate firm existing strategies.  In general, the purpose of forming EFE matrix is to evaluate whether the organization is capable of exploiting the opportunities and avoiding threats (17). In this matrix, first, the detected opportunities (O) and threats (T) are listed. Then a factor of importance or weight from 0 (not important) to 1 (very important) is assigned to each O/T. These weights indicate the relative importance of particular factors in the success of the organization under study. The sum of these factors must be 1. Then, each of them is scored from 1 to 4 (1 for a major threat, 2 for a minor threat, 3 for a minor opportunity and 4 for a major opportunity). Table 2 exhibits the importance factor and rank of each opportunity/threat obtained through av-eraging experts' opinions. In the next phase, the importance factor of each item is multiplied by its rank to obtain the final score. Likewise, the overall score of the organization is obtained. If this score is less than 2.5, the organization faces a threat. Otherwise, it means that the organization faces an opportunity. According to Table 2 and EFE matrix, the final score of SSO in medical tourism is 3.40. This score indicates that the opportunities facing the organization are more than threats. SSO can boost its capabilities by exploiting these opportunities. On the other hand, if appropriate measures are not taken for eliminating the threats, opportunities are more likely to be wasted in the long-term.  Besides analyzing the external factors, it is also necessary to examine the organization's internal factors. Table 3 illustrates the importance factor/or weight and rank of each S/W obtained through averaging experts' opinions. In the next phase, the overall score for the organization is obtained. If this score is less than 2.5, it means that the organization is weak in terms of the in-ternal factors. Otherwise, the organization is strong in terms of these factors. In Table 3, the final score resulting from IFE matrix is 2.42, which indicates that the strengths of the organization in the field of medical tourism are less than its weaknesses. Focus group approach has been used for providing a list of effective strategies in the field of medical tourism.
For this purpose, focus group session was held with 10 members of tourism managers and medical care experts. The members were offered with the SSO's IFE and EFE matrices and they were asked for discussing the formulation of strategies. The output of this phase is a list of the organization's strategies in the field of medical tourism. Table 4 displays four zones for aggressive, conservative, competitive and defensive strategies.

Findings of the third phase
Strengths (S), Weaknesses (W), Opportunities (O) and Threats (T) are linked to each other in 4 ways: SO, WO, ST and WT, which give the strategic options. Table 4 summarizes the SSO strategies in the field of medical tourism using the experts' opinions about the importance factor of internal/external factors. The final internal/external factors (FIEF) matrix reveals which of the four zones of SWOT matrix will include aggressive, conservative, competitive and defensive strategies based on the SSO conditions (Table 5). The score is 2.42 for IFE and 3.40 for the EFE matrix, according to Tables 2 and 3, respectively. These scores indicate zone  in Table 5.
This zone is characterized with weaknesses in terms of internal evaluation and opportunities in terms of external evaluation. According to Table 5, Iran's Social Security Organization should follow conservative strategies for boosting medical tourism. These strategies are as follows:  Designing targeted and coherent planning for the attraction of medical tourists to the organization's hospitals (WO1)


Attempts towards international standardization of medical centers concerning the qualification for accreditation certificates of ACI and JCI (WO2)


Training the medical staff regarding communications skills and international lan- Developing a comprehensive website for the organization's medical centers (WO4). Attempts towards international standardization of medical centers concerning the qualification for accreditation certificates of ACI and JCI (WO2) 3.
Attempts towards training the medical staff regarding communications and international languages (WO3) 4.
Attempts towards running a comprehensive internet network for the organization's medical centers/services (WO4) (Strategy: Using opportunities for reducing the organization's weaknesses in medical tourism)

Competitive strategies(ST)
Defensive strategies(WT) Threats(T) 1. Active participation in the formulation of comprehensive laws in relevant organizations such as the Ministry of Health and Medical Education (ST1) 2. Formulating inner-organizational regulations concerning medical tourism (ST2) 3. Introducing price advantages in comparison to private hospitals (ST3) (Strategy: Using the organization's strengths in medical tourism to reduce environmental threats) 1. Investment in promoting hoteling level in self-owned hospitals to compete with private hospitals (WT1) 2. Creating an incentive system for the medical staff to enhance the quality of services provided for medical tourists (WT2) (Strategy: Conservative performance to prevent environmental threats) Source: Research findings In Table 6, pairwise comparison is carried out among the criteria, and their relative importance is evaluated. According to Fig. 1, the inconsistency rate for the criteria is 0.02, which indicates an acceptable precision for pairwise comparison. All strategies were compared in pairs considering each criterion. Figures 2-5 depicted the weight of each criterion and its impact on the options. According to the outputs of Expert Choice software reported in Fig. 6, the best option is WO1 (Designing targeted and coherent planning for attracting medical tourists). Then comes WO4 as the second priority, and the third priority is WO3, and finally WO2. Regarding the total inconsistency rate, which is equivalent to 0.03, pairwise comparisons are consistent, and research findings are valid.

Discussion
This paper aimed to identify strategies for medical tourism development in SSO using SWOT-AHP hybrid method in Iran. Regarding the external factors influencing medical tourism in SSO; the weight of the opportunities facing the organization is more than that of threats, which indicates potential opportunities for the organization to enjoy the advantages of medical tourism.  (10). In particular, the employment of qualified, and bilingual or trilingual staff in host hospitals, and upgrading technological capabilities are regarded as common strategies in Iran and Turkey. In a comparison of potentials of medical tourism in Iran and India, India relative to Iran is of more strengths and opportunities. Thus, Iran has been recommended to apply India' experiences in expanding curative tourism (2). In this regard, health tourism development strategies include lowering prices of medical services, utilizing religious, cultural and linguistic similarities to attract health tourists from neighboring countries, advertising in the field of health tourism potentials and attractions. Upgrading quality and standard of providing medical services is a common strategy proposed by current study and as a practical solution to develop medical tourism, medical staff should be trained regarding communicative and linguistic skills. This point has not been considered in (2). The results are also like findings of (9) focusing Tehran private hospitals, in which authors identify improving public infrastructure, developing human resources, upgrading information systems, promoting marketing and product development as main strategies for expanding medical tourism. Hence, this study recommends a "targeted and coherent plan" for attracting medical tourists to the SSO's hospitals. In Iran, most health/medical tourism researches have centered on national or local case studies, and no study has ever been done for the SSO's hospitals. This research uniquely focuses on the selected hospitals of the SSO, and recommends targeted planning, accredited medical centers, trained and skilled medical staff, and on-line marketing at organizational level.

Conclusion
In Iran's development plans and its vision 2025, this organization has the capacity for running the industry. The results indicate the higher weight of the organizational weaknesses in medical tourism compared to its strengths in the field. The managers and decision-makers of the organization should focus their utmost attention on weakness-es of the organization. These include weak planning, lack of proficiency in international languages among the medical staff, lack of multilingual websites on medical services, lack of international standards of hospital accreditation and lack of marketing for attracting medical tourists. In summary, four strategies are proposed for developing medical tourism by Social Security Organization as follows: 1. Designing targeted and coherent planning for attracting medical tourists to the organization's hospitals (WO1) 2. Attempts towards international standardization of medical centers concerning the qualification for accreditation certificates of ACI (Accreditation of Canadian International) and JCI (Joint Commission International) (WO2) 3. Training the medical staff regarding communications and international languages (WO3) 4. Attempts towards running a comprehensive internet network for the organization's medical centers (WO4).

Ethical Considerations
Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.