Ranking of Sustainable Medical Tourism Destinations in Iran: An Integrated Approach Using Fuzzy SWARA-PROMETHEE

sustainability
Article
Ranking of Sustainable Medical Tourism Destinations in Iran:
An Integrated Approach Using Fuzzy SWARA-PROMETHEE
Peiman Ghasemi 1 , Amir Mehdiabadi 2 , Cristi Spulbar 3 and Ramona Birau 4, *
1 Department of Industrial Engineering, South Tehran Branch, Islamic Azad University,

Tehran 1584743311, Iran; st_p_ghasemi@azad.ac.ir
2 Department of Management, South Tehran Branch, Islamic Azad University, Tehran 1584743311, Iran;
Amir.mehdiabadi@gmail.com
3 Faculty of Economics and Business Administration, University of Craiova, 200585 Craiova, Romania;
cristi_spulbar@yahoo.com
4 Faculty of Education Science, Law and Public Administration, Constantin Brancusi University of Targu Jiu,
210135 Targu Jiu, Romania
* Correspondence: ramona.f.birau@gmail.com; Tel.: +40-767-970-777
Abstract: Today, medical tourism is one of the fastest growing sectors of the tourism industry
around the world. Medical tourism can contribute to the sustainable development and economic
dynamism of countries. Therefore, in this study, we prioritize the world’s leading countries in
medical tourism for Iranians. First, five main criteria and 20 sub-criteria were selected, which are
the reasons for choosing a country as a medical tourism destination. In this paper a combined
fuzzy SWARA-PROMETHEE approach was used to prioritize tourism destinations. The acronym
PROMETHEE stands for Preference Ranking Organization Method for Enrichment Evaluation
method and represents an useful MCDA (Multi-Criteria Decision Analysis) tool. On the other
hand, SWARA acronym means Step-wise Weight Assessment Ratio Analysis. The criteria were

weighted using the fuzzy SWARA approach. In the following, using the PROMETHEE approach, we
prioritized eight countries as tourism destinations, then we identified criteria related to sustainability
Citation: Ghasemi, P.; Mehdiabadi,
A.; Spulbar, C.; Birau, R. Ranking of
of medical tourism destinations and prioritized medical tourism destinations using these criteria as
Sustainable Medical Tourism the contributions of this paper. The weights obtained for criteria “Abilities of skilled staff,” “Applied
Destinations in Iran: An Integrated medical equipment,” “Marketing capability,” “Type of service provided,” and “Application of
Approach Using Fuzzy information and communications technology” were 0.176, 0.232, 0.108, 0.395, and 0.089, respectively.
SWARA-PROMETHEE. Sustainability The results show that medical tourism destination priorities for Iranians are India (Phi = 0.1396),
2021, 13, 683. https://doi.org/ Malaysia (Phi = 0.1128), Panama (Phi = 0.0976), Mexico (Phi = 0.0790), Singapore (Phi = 0.0096),
10.3390/su13020683 Taiwan (Phi = −0.0442), Brazil (Phi = −0.1747), and Costa Rica (Phi = −0.2196), respectively. Negative
Phi values indicate below average performance of those countries and positive Phi values indicate
Received: 9 December 2020
above average performance of those criteria. The results indicate that countries with negative Phi
Accepted: 8 January 2021
values should be strengthened relative to the improvement of some criteria.
Published: 12 January 2021
Keywords: medical tourism; fuzzy SWARA; PROMETHEE; sustainable development; consumer;

Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional clai-
medical tourism destinations
ms in published maps and institutio-
nal affiliations.
1. Introduction
In recent decades, especially during the last 30 years in the application of new meth-
Copyright: © 2021 by the authors. Li- ods in the sub-sectors of the tourism industry, many efforts have been devoted to the
censee MDPI, Basel, Switzerland.
sustainability of such activities. Until the late 1970s, tourism was introduced as a golden
This article is an open access article
activity without drawbacks, and its positive consequences, especially its economic benefits,
distributed under the terms and con-
were always emphasized [1]. Numerous research findings and reports since the 1980s have
ditions of the Creative Commons At-
confirmed the adverse environmental, social, and cultural consequences of tourism. In
tribution (CC BY) license (https://
the 1990s, in line with the sustainable development paradigm, traditional approaches to
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tourism development were challenged, and with a simultaneous emphasis on the favor-
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Sustainability 2021, 13, 683. https://doi.org/10.3390/su13020683 https://www.mdpi.com/journal/sustainability

Sustainability 2021, 13, 683 2 of 32
able and unfavorable consequences of tourism, the movement from mass tourism to the
approach to sustainable tourism development began [2].
Tourism as well as medical tourism can be sustainable if developed and managed,
considering visitors/medical tourists and local communities/health care centers [3]. This
can be achieved through community engagement, congestion management, reduction of
seasonality, careful planning that respects the limits of capacity and the specificities of each
destination, and product diversification [4,5]. Medical tourism is a type of tourism that
happens in order to maintain, improve, and regain the physical and mental health of an
individual in a period of more than 24 h and less than a year [6]. According to Connell
(2013) medical tourism can be perceived as a vacation that entails traveling into foreign
countries to access a wide range of health services [7]. Zarei et al. [8] defined medical
tourism as an individual’s travel for treatment (whether through medical intervention or
the use of natural resources), rest, and maintaining physical health. This travel can be
voluntarily or on the advice of a doctor [9].
Factors that include improving medical standards in developing countries, global-
ization and free trade in health care services [10], development of the Internet, and the
emergence of communication companies that act as intermediaries between international
patients and hospital networks and provide patients with easy access to information and
prices, together with advanced technologies created with new care services have paved
the way for the rapid growth of medical tourism [11]. In addition to the above, issues such
as demographic changes in developed countries along with increasing problems in their
health care systems such as long queues of patients, high costs of health services, and high
rates of non-insurance coverage cause patients to travel from these countries to receive
high quality and low cost health services [12].
Hadian et al. [13] defined medical tourism as a patient’s travel to receive healing
or disease aggravation preventive services outside the usual living environment for a
minimum of one day and a maximum of one year, adding that the travel of healthy people
who accompany the patient during this period should be considered a part of medical
tourism. In general, medical tourism is any travel to promote health (for an individual or
one of their family members) [14].
With global revenues of about USD 20 billion in 2005, it is one of the world’s largest
industries [15]. The medical tourism market included 19 million trips with a total value of
USD 20 billion in 2005 [16]. According to the latest report, global medical tourism market
was valued at approximately USD 65.5 billion in 2019 [17].
The increase in the number of uninsured people in Western countries as well as the
increase in health care costs has led people to choose treatment abroad. Many countries
are experiencing high growth in medical tourism [18]. As an interdisciplinary approach,
Ganguli and Ebrahim (2017) revealed that medical tourism, which is a rapidly growing
market, has been recognized by many countries as a potential sector for economic diversifi-
cation [19]. The World Tourism Organization (WTO) specifically defines medical tourism
as: Use of services that improve or enhance a person’s health and well-being (using mineral
water, weather, or medical interventions) in a place outside the person’s residence that lasts
longer than 24 h. The global motto of health tourism is facilities and services at the level of
the first or advanced countries of the world, and prices and costs at the level of developing
countries and the third world [20].
The concept of health tourism was originally introduced by the International Union
of Tourist Organizations (IUTO), which is the predecessor of UNWTO, in 1973. In other
words, IUTO provided the following definition for health tourism, such as: “the provision
of health facilities utilizing the natural resources of the country, in particular mineral water
and climate” [21]. According to UNWTO/ETC’s report on health tourism launched in
2018, health tourism “covers those types of tourism which have as a primary motivation
the contribution to physical, mental and/or spiritual health through medical and wellness-
based activities” [22].
By 2025, it is predicted to grow to 500 million travels, or 10% of global tourism [23].
The number of medical tourists is also expected to increase exponentially [24]. For example,
in Taiwan the number of medical travelers is expected to increase to 777,523 by 2025 [25].
In developed countries, each of the following issues can motivate people (demand side) to
receive these services in other countries despite some problems such as lack of insurance
coverage and the high cost of treatment [26]. Connell (2013) argued that familiarity with
destinations represents a facilitator for potential medical tourists to select a particular
country [7]. In addition, Heung et al. (2010) identified certain advantages of the medical
tourism industry such as: increasing gross domestic product (GDP), improving medical
services, and generating foreign exchange [6]. The following are some of the reasons for
medical tourism:
Cost: The cost advantages of developed countries and new industrialized countries in
the field of medical services have caused the emergence of this phenomenon [27]. The main
direction of medical tourism can be from developed to developing countries or vice versa.
People travel from developing countries to developed countries to use higher medical
facilities and technologies. Also people travel from developed countries to developing
countries due to the availability of cheaper medical services [28].
Growth in demand: In recent years, the demand for health care has increased in
developed countries for reasons such as the aging population [29]. This issue lengthens the
waiting time of patients.
Insurance: Due to the high cost of health insurance, a large group of people in
developed countries do not have this insurance. Lack of insurance coverage for many
cosmetic surgeries is another reason for the increase in medical tourists [19].
In addition, medical tourism in developing countries (supply side) has increased
for the following reasons: 1. Globalization and liberalization of trade in the field of
health services have caused the rapid growth of medical tourism [30]. 2. The growth and
expansion of airlines has made it possible to use medical services in remote destinations [31].
3. The Asian financial crisis has led governments to seek new sources of income [19]. 4.
Favorable exchange rate changes in the global economy have made Asian countries suitable
destinations for tourism [32]. 5. Rapid improvement of equipment [33].
The leading countries in the field of medical tourism are as follows [34]:
• Brazil: It is one of the oldest countries in medical tourism, which owes much of its
fame to cosmetic surgery, but non-cosmetic surgery has little history in Brazil. The first
hospital to be accredited by Joint Commission International (JCI) standards outside
the United States was a hospital in Brazil that received the commission’s certification.
• Costa Rica: Recently, Costa Rica has made great efforts in the field of medical tourism
and has been one of the leaders of this industry since 2007. Costa Rica currently has
three JCI-accredited hospitals, all three of which are in San José.
• India: One of the most important Asian countries in the field of medical tourism, with
22 hospitals, all of which have received JCI certification. Indian medical tourism is
very popular in the world. Moreover, the main reason in attracting tourists to India is
the relative cheapness of goods and services compared to other countries.
• Mexico: A very attractive destination for medical tourists, especially Americans.
Americans living in the southern states bordering Mexico, such as New Mexico,
Arizona, or Texas, go to Mexico almost routinely to receive cheap medical treatment.
• Panama: Amazing attractions, bilingual physicians, having international documents
and standards, using the US dollar so the tourists do not need to convert their money.
These reasons have made Panama one of the leaders in the international medical
tourism industry.
• Singapore: This country has several JCI-accredited hospitals. Singapore’s health stan-
dards are very high. According to the World Health Organization, in 2000 Singapore
had the sixth best health care system in the world, and the first in Asia.
• Taiwan: The government of Taiwan officially announced its intention to make its coun-
try a medical tourism center, and in 2007 the Taiwan Ministry of Health implemented
a plan to raise the level of all medical services in the country.
• Malaysia: Malaysia provides guests with the best medical facilities in terms of cost.
Most Malaysian medical tourists are from Southeast Asia because the cost difference
is very high, and in addition, people in Muslim countries prefer to go to Malaysia for
treatment because of the Malaysian Islamic culture.
Some other researchers argued that India, Indonesia, Malaysia, the Philippines, Sin-
gapore, Thailand and many other countries market themselves as major destinations
for medical tourism [35]. Al-Talabani et al. (2019) suggested that countries like UAE,
India, and the Philippines are leading, emerging major health care destinations, consid-
ering that health tourism represents at the moment a USD 100 billion global business,
while this particular kind of tourism is currently experiencing an average growth rate of
25% [4]. In addition, Lunt and Carrera (2011) highlighted the fact that medical tourism is
an interdisciplinary trend, important in various disciplines, including inter-institutional
cooperation [36].
Documentary and field studies in the field of health tourism in Iran show that, al-
though health tourism in Iran has long been the focus of tourists and foreign patients
entering the country and in recent years its organizational and legal management has
begun, it is undergoing its first development and is facing the challenges that have arisen
following the general conditions of the country in order to achieve its worthy position.
These challenges are as follows:
A. Lack of a clear strategy and agency for health tourism at the international, national,
and regional levels. Despite the introduction of tourism in the laws of the Islamic
Republic of Iran as one of the pillars of economic development, the share and position
of this sector in the economy is not fully understood and lacks a clear long-term
strategy in dealing with domestic and foreign tourism applicants. Health tourism
in Iran has more than 60 institutions and stakeholders, all of which, based on their
organizational duties and powers in the field of tourism and health tourism, claim to
participate in management and do not have a proper response.
B. Lack of a comprehensive health tourism system, definition and formulation of laws,
policies and programs.
C. Lack of infrastructure, including communication infrastructure, training infrastructure
for health tourism professionals, infrastructure of medical facilities and equipment,
infrastructure for welfare and accommodation services of health tourists and their
companions, legal infrastructure.
D. Lack of a codified and strong monitoring system; different quality of public and
private centers, especially in the field of service quality; and weaknesses and short-
comings in the accreditation system.
E. Weakness in process management and design of standard service packages that can
be provided to health tourists, such as: uncertain price of services, especially in the
private sector; lack of a program and system for alternative, traditional and herbal
medicine; and lack of medical tourism insurance, non-acceptance of medical tourism
insurance coverage.
F. Lack of necessary private sector support from the government; lack of definition and
explanation of the position of the private sector and the use of its many potentials;
the tendency to governmentalize the issue despite previous unsuccessful experiences;
and the weak role of private hospitals and trade unions.
G. Lack of integrated information management systems (M.I.S); lack and delay in estab-
lishing a system of registration, control, and statistics of health tourists; and lack of
infrastructure and basic information of hospitals.
H. Lack of a clear marketing system, the presence of brokers and intermediaries along
with providing inappropriate services at different prices, lack of marketing insti-
tutions, lack of foreign marketing research, lack of overseas advertising system,

insufficient knowledge of target markets, and poor marketing efforts.
The purposes of this research study are to select and rank the medical tourism des-
tinations for the Iranian people. Therefore, at first, the sustainable criteria of medical
tourism destinations are identified. In the following, using the fuzzy SWARA method, the
weights of the identified criteria are determined based on the decision of experts. After
determining the weights of the criteria, the medical tourist destinations are prioritized
using the PROMETHEE method. The contributions of paper are as follows:
• Identify criteria related to sustainability in the subject of medical tourism destinations,
• Prioritize medical tourism destinations using a fuzzy SWARA-PROMETHEE approach,
• Investigating the strengths and weaknesses of medical tourism destinations based on
sustainable factors,
• Application of the model to a real-world case study in Iran.
Therefore, the research questions are as follows:
1. What are the sustainable criteria for medical tourism purposes?
2. What are the medical tourism priorities of patients in Iran?
3. How to prioritize tourist destinations with a hybrid fuzzy SWARA-PROMETHEE
method?
4. How does the prioritization of tourist destinations change with the change of sustain-
able criteria weights?
5. Which tourist medical destination country has performed poorly or strongly in terms
of criteria?
This research is presented in five sections. In the first section, the introduction is
mentioned. In the Section 2, the literature review is mentioned. This section is divided to
medical tourism, medical tourism and sustainability, and analysis methods sub-sections.
The materials and methods are presented in the Section 3. The results and discussions
are described in the Section 4. Finally, conclusions are presented in the Section 5 of our
research paper.
2. Literature Review
The literature review section is divided into two parts, including medical tourism and
analysis methods.
2.1. Medical Tourism

Medical tourism is the most sensitive type of tourism among all types of tourism,
because it is directly related to the life and health of the tourist. Although many countries
in the world today offer health tourism services to earn money, the potential of a country
in medical science and medical services, unlike recreational and sports tourism, is cer-
tainly not something that can only be achieved through construction and spending money.
Therefore, identifying sustainable criteria for medical tourism destinations and prioritizing
destinations can help patients to choose destinations tailored to their needs. Sustainable
criteria cover all economic, social, and environmental dimensions. Therefore, identifying
and prioritizing criteria can help tourism destinations to strengthen strengths and reduce
their negative criteria [37].
Perkumiene et al. (2019) argued that sustainable medical tourism represents “an
emergent and growing business worldwide, combining different and very specific purposes
from pleasurable travel to sometimes-stressful services of health care” [3]. Lunt and Carrera
(2011) suggested that medical tourism is related to the idea of a person traveling to a foreign
country with the purpose of receiving medical procedures, with an emphasis on “clinical,
surgical, and hospital provision” [36]. Kim et al. (2019) considered that medical tourism
represents the phenomenon of traveling across national borders intentionally to access a
variety of medical treatments, especially modern medical treatment [28]. Khan et al. (2020)
suggested that international medical travel is defined as “the citizens of source country
travel to foreign destination hospitals with the sole purpose of obtaining necessary medical
procedures and treatment” [38].
Gan and Frederick (2011) revealed that medical tourism agencies (facilitators) actually
include the organizations specializing in arranging suitable foreign hospitals and treatment,
transportation, and lodging during recuperation [39]. Moreover, Hall (2011) revealed
the existence of certain interrelationships between different areas of health and medical
tourism, including wellness and well-being tourism, dental tourism, stem cell tourism,
transplant tourism, abortion tourism, and xeno-tourism [40].
Some researchers [35] suggested that the concept of “medical tourists” includes those
patients trying to avoid treatment delays and obtain timely access to health care. Kangas
(2010) argued that terminology for medical travelers ranges from “medical tourists” to
“medical exiles” [12]. Lee and Li (2019) argued that travel medicine is related to traveling
to different countries for disease prevention, injury, immunology, infectious diseases, and
vaccination, while medical travel is used for health inspections and plastic surgery, and
involves medical treatment, rehabilitation, and self-care [41]. On the other hand, Wu and
Guo (2014) mentioned that most people choose to take a getaway out of town in order to
relax, improve their physical fitness, and engage in social activities, because of the natural
environmental factors, including sound, temperature, humidity, atmospheric pressure, air,
light, and lack of crowds [42].
The World Tourism Organization (UNWTO) defines the concept of sustainable tourism
as: “Tourism that takes full account of its current and future economic, social and envi-
ronmental impacts, addressing the needs of visitors, the industry, the environment and
host communities” [21]. Spulbar et al. (2019) argued that, naturally, every country in the
world needs to exploit its tourism potential in order to attract foreign capital for sustaining
tourism and the hospitality industry [43]. To increase sustainable tourism it would be
advisable to provide an increased level of customer satisfaction in order to facilitate the
fulfillment of significant expectations for tourists, while raising their awareness about
sustainability issues and promoting sustainable tourism practices among them [21].
The following Table 1 illustrates the difference between this work and the previous
studies in literature. The literature review table is divided as follows:
1. Identify Criteria: In some articles, the criteria are identified by experts. In other
articles, existing criteria or criteria of other researches are used.
2. Outranking method: A classical problem in the field of multiple-criteria decision-
making (MCDM) is to build a preference relation on a set of multi-attributed al-
ternatives based on preferences expressed on each attribute and “inter-attribute”
information such as weights. Based on this preference relation (or, more generally,
on various relations obtained following a robustness analysis) a recommendation is
elaborated (e.g., exhibiting a subset likely to contain the “best” alternatives).
3. Fuzzy: Some studies consider data to be fuzzy to bring the problem closer to the real
world, and others consider data Crisp.
4. Sustainability: Concurrent attention to social, economic, and environmental criteria is
called sustainability.
5. Methods: These include a variety of mathematical or decision-making approaches.
6. Real case study: Some studies consider a real case study and others consider a
numerical example.
Table 1. Literature review.
Paper Identify Criteria Out-Ranking Method Fuzzy Sustainability Methods Real Case Study
Khan et al. (2020) [38] • Conceptual framework •
Çavmak and Çavmak (2020) [44] • AHP •
Perkumiene et al. (2019) [3] • • Conceptual framework
Farzin et al. (2019) [45] ANFIS-SVR •
Nilashi et al. (2019) [46] • • DEMATEL-F.TOPSIS •
Kim et al. (2019) [28] • Conceptual framework •
Lou et al. (2019) [47] • • AHP •
Yıldız and Khan (2019) [48] • AHP •
Arif et al. (2019) [49] TOPSIS •
Mayakul et al. (2018) [50] • • Conceptual framework •
NajafiNasab et al. (2018) [51] • SEM •
Rezaeenour et al. (2018) [52] • AHP and TODIM •
Karami et al. (2017) [53] • • AHP •
MorovatiSharifabadi and
• TOPSIS-SEM •
AsadianArdakani (2014) [54]
Tsaur and Wang (2007) [55] • F. AHP •
This paper • • • • SWARA-PROMETHEE •
Source: Author’s own contribution.
Dreisbach et al. [56] discussed certain issues such as: cancer, tourism, and the relation-
ship between tourism and health. In this study, a model was presented that could reflect
and easily explain the need of these patients to go on vacation at different stages of the
disease. During the course of the disease, people look for different ways of rehabilitation
and comfort, such as alternative and complementary therapies and support groups. They
may be able to access such help by going on vacation. Nilashi et al. [46] stated that medical
tourists are guests of a hotel that devotes its time to a specific medical activity, so it is
a product of tourism and the health sector. They considered the people who come for
treatment as guests who devote only part of their time to a specific treatment and may use
the rest of their time for other activities. In this study, tourism was considered along with
the health sector, and the welfare facilities of medical tourism were considered, but the
type of facilities was not mentioned.
Ahire et al. [57] examined the details of today’s medical tourism creation. They
compared prices in developing and developed countries, examined the medical tourism
attractions and the available facilities, and stated that medical tourism has been created to
meet the needs of a number of people, mostly from developed countries. The main centers
of tourism are developing and mostly Asian countries, including India. Medical tourism
in India accounts for 8.6% of India’s GDP. Medical tourism includes the largest foreign
financial transactions for these countries, as well. The medical tourism industry generated
about USD 5 billion in revenue for India in 2018. This amount of GDP was the highest
income from medical tourism in the world in 2018 [57].
Hall (2011) argued that the development of international medical tourism is demon-
strated to have potentially significant implications for global public health [40].
2.2. Medical Tourism and Sustainability

Tourism is growing and developing very fast in the present era. Increasing demand
in terms of quantity and quality can be considered the reason for this [3]. The laws and
regulations of different countries indicate this [58]. However, it is very difficult to accu-
rately define the types of tourism and the types of communications, information systems,
and various services, other than from economic, social, and cultural perspectives [59].
Medical tourism is one of the most important and important types of tourism on which
different countries cooperate bilaterally or multilaterally [3]. The economic benefits of
medical tourism are many; governments, residents, and various businesses are beneficia-
ries of this type of tourism. It can also reduce the cost of transporting and exchanging
information [60,61].
Medical tourism is a kind of cultural confrontation between nations [62]; while they
are considered tourists, they can travel long distances in order to receive a variety of
medical services [7].
The medical tourist experiences the thrill of traveling and makes the best use of the
potential services of the target country. Lower costs, quality of services, unavailability
of internal facilities, long waiting queues, etc., are the main reasons for people traveling
for medical tourism [63,64]. Medical tourism will involve both the private and public
sectors [65]. The important point is to correctly and accurately identify the pillars of
tourism development in this chain [66].
In other words, by identifying lifestyles, types of luxury, and globalization, and
moving toward sustainability and types of consumer behavior, medical tourism can con-
tribute to sustainable development [67]. Sustainable medical tourism as a multifaceted
phenomenon has several definitions [66,68,69]. The focus of tourists on quality products
and services is in fact a requirement to meet their physical, social, and spiritual needs
through the development of sustainable tourism and the provision of desirable services [70].
The significant increase in the number of medical tourists in recent years is directly and
indirectly determined by environmental indicators on human health and well-being [71].
The results of numerous researches of scientists show that there are two motivations in
medical tourists to travel: the first is related to the economic situation, political climate, and
hospitality standards, and the second is related to medical service providers in the target
country, which includes costs, accreditation standards, and service quality, including pro-
fessional qualifications [3]. In fact, the development of sustainable tourism is to strengthen
the opportunities ahead while maintaining the needs of tourists [3]. All resources and
facilities must be mobilized to maintain cultural interaction, environmental, economic, and
social and information sharing needs. In many scientific sources, the subject of sustain-
ability refers to: 1—ideal natural resources, 2—respect for the comprehensive cultural and
social originality of the host, 3—ensuring positive and sustainable economic performance,
4—providing social and economic benefits for all stakeholders, 5—participation of all
stakeholders, 6—satisfaction of tourists [30,72].
In some sources, providing high quality services is the key to sustainable competitive
advantage [73]. The need to pay attention to the sustainable development of medical
tourism along with the positive economic impact on the host community and surrounding
areas as well as the access of millions of people to a variety of affordable medical services
can create strong social impacts [3]. Tourists’ experiences of traveling to countries tar-
geted for medical tourism can be valuable. Then, creating a chain of cooperation between
governments to strengthen the opportunities for medical tourism and introduce differ-
ent services to each other can lead to sustainable economic, social, environmental, and
cultural development.
2.3. Iranians and Medical Trips

Despite the various facilities inside the country, Iranians in some cases prefer to travel
to different countries to do the following:
- Medical Tourism: This type of trip is done to treat the disease, perform surgery, or
check the health of the tourist in the clinics and hospitals of the destination country.
The existence of experienced physicians, medical history, medical and supervisory
infrastructures, standard hospitals and clinics, complete and up-to-date medical
equipment, as well as laws and medical supervision are among the important medical
infrastructures of the destination country.
- Curative Tourism: Travel to countries with natural healing resources such as hot
springs, salt lakes, mud baths, clean environment, and bright sunshine is included in
the nature tourism. On this type of trip, skin, respiratory, rheumatology, and muscle
patients travel to these areas for medical massage, herbal baths, as well as to recover
from treatment and surgery.
- Wellness Tourism: In health tourism, the tourist travels to get rid of the stresses of
daily life and seek peace. Usually, these tourists do not have a specific physical illness
and are more interested in enjoying the healing nature and avoiding the hustle and
bustle of urban life. Health tourists travel for a variety of services, including fitness
and exercise, beauty treatments, healthy eating and weight management, relaxation
and stress reduction, meditation, yoga, and health-related training.
2.4. Benefits and Reasons for Choosing Health Tourism as a Treatment

There are many reasons why Iranians go abroad for medical treatment, the most
important of which are:
- Disappointment with treatment in their home country,
- Lack of access to medical care at an appropriate time and cost,
- Insufficient insurance and income to cover the costs of local health services,
- High quality medical care in developing countries,
- Variety of treatment options,
- Desire to receive medical care away from a monotonous and permanent place (escapism),
- Lack of waiting list,
- Growing popularity for overseas medical services,
- Access to the latest technologies,
- Existence of oppressive sanctions and access to all kinds of drugs.
2.5. Analysis Methods

2.5.1. Analytic Hierarchy Process (AHP) and Analytic Network Process (ANP)
Çavmak and Çavmak (2020) identified and prioritized 23 medical tourism barriers
in Turkey. They divided the barriers into five general categories and prioritized them
with an AHP approach. The criteria considered included the following: target brand,
social issue, tour holder, target market, tourism product, and communication channels [44].
Lou et al. (2019) presented the risk factors in the sustainable development of healthy
cities using the AHP approach. The criteria considered included the following: “safety,”
“sustainable ecology,” “vitality and health,” “culture friendly” and “convenience and pros-
perity.” The results indicated that safety is selected as the most important criterion [47].
Yıldız and Khan (2019) investigated the aspects that are considered relatively more impor-
tant by medical tourists from the Arab region in Turkey. Two indicators of performance and
importance were considered to evaluate the proposed criteria with the collected question-
naire. The results indicated the appropriate performance of the AHP approach to prioritize
options [48]. Rezaeenour et al. (2018) in Iran evaluated the quality of hospital services,
with the aim of developing medical tourism, with a combined approach to fuzzy AHP
and TODIM [52]. Moreover, TODIM is the Portuguese abbreviation for Interactive and
Multi Criteria Decision Making. Roy et al. (2017) in an attractive study evaluated and
selected medical tourism sites based on the R-AHP and R-MABAC approach [74]. The
acronym MABAC stands for Multi-Attributive Border Approximation Area Comparison.
In their study, Görener and Taşçı (2016) evaluated medical tourism strategies based on
the SWOT framework with a combined AHP and MOORA approach [75]. The acronym
SWOT is based on the following key elements: Strengths, Weaknesses, Opportunities,
and Threats, while MOORA framework stands for Multi-Objective Optimization by Ratio
Analysis. In a study, Levary (2011) ranked medical tourism destinations by AHP [57].
Bies and Zacharia (2007) addressed the issue of outsourcing surgery (Outsourcing Surgical
Care) in medical tourism using the ANP approach [76].
2.5.2. TOPSIS
Arif et al. (2019) investigated medical tourism destination priority in Batu City. They
presented the 6AsTD framework and TOPSIS method as a combination concept to rank
medical tourism destinations. TOPSIS represents one of the MCDM (Multiple Criteria
Decision Making) methods with a large applicability. The acronym TOPSIS stands for
Technique for Order Performance by Similarity to Ideal Solution. The 6AsTD method has six
criteria that reflect successful medical tourism destinations. The research results indicated
the appropriate performance of the proposed combined approach [49]. Rezaee (2019)
investigated the location of medical tourism destinations in Charmahal and Bakhtiaree
Province. They used GIS model for locating destinations and used the TOPSIS method
for ranking them. The results showed that Chelgerd was selected as the best tourist
destination [77]. Nilashi et al. (2019) presented factors that influenced medical tourism in
Malaysia. They considered environmental, human, and technological factors. The data
were collected from hotel managers. They used fuzzy TOPSIS and DEMATEL methods
for ranking alternatives. On the other hand, the acronym DEMATEL stands for Decision
making trial and evaluation laboratory. Finally, the results showed that technological
factors are the most important factors [46].
2.5.3. DEMATEL
Farzin et al. (2019) used fuzzy Delphi and fuzzy DEMATEL to predict the demand for
medical tourism in Tehran (Iran) [45]. Modiri et al. (2017) in their research selected medical
tourism strategies based on the SWOT framework with a combined approach of fuzzy
DEMATEL, fuzzy ANP, and fuzzy VIKOR [78]. The acronym VIKOR is in Serbian language
and stands for vlseKriterijumska Optimizacija I Kompromisno Resenje and also represents
a multi-criteria decision making (MCDM) method. Taghvaei and Goodarzi (2016) also
prioritized medical tourism strategies with a combination of fuzzy DEMATEL, fuzzy ANP
and AHP [79]. Chen (2012) used the DEMATEL approach to develop medical tourism in
Taiwan [80].
2.5.4. VIKOR
Taghizadeh Yazdi and Barazandeh (2016) evaluated and prioritized the barriers to the
development of health tourism in Iran with a fuzzy VIKOR approach [81]. Hung et al. (2014)
improved
Sustainability 2021, 13, x FOR PEER REVIEW medical screening services with a combined DEMATEL-ANP 11 (DANP)
of 32 and
VIKOR approach [82].
2.5.5.al.
Other Techniques
(2014) improved medical screening services with a combined DEMATEL-ANP
(DANP) and VIKOR
Abouhashem Abadi approach [82]. evaluated medical tourism strategies in their research
et al. (2018)
study based on the best–worst method (BWM) approach [83]. Although Iran has been very
2.5.5. Other Techniques
successful in providing medical services in recent years, there is not a global priority for
Abouhashem Abadi et al. (2018) evaluated medical tourism strategies in their
medical tourism. Therefore, in this research, with a fuzzy approach, we seek to identify
research study based on the best–worst method (BWM) approach [83]. Although Iran
the medical
has beentourism criteria in
very successful and prioritize
providing the most
medical important
services in recentcountries regarding
years, there is not a medical
tourism forpriority
global the Iranians.
for medical tourism. Therefore, in this research, with a fuzzy approach,
we seek to identify the medical tourism criteria and prioritize the most important
3. Materials
countriesand Methods
regarding medical tourism for the Iranians.
The main objective of this research study was to select and rank the medical tourism
3. Materials and Methods
destinations for the Iranian people. Questionnaires on the motivation of individuals to
The main objective of this research study was to select and rank the medical
choose medical tourism destinations were distributed and collected during 2019. According
tourism destinations for the Iranian people. Questionnaires on the motivation of
to theindividuals
populationtosize, which
choose was 750
medical people,
tourism the sample
destinations weresize was calculated
distributed as 256 people,
and collected
basedduring
on the Cochran method. The statistical population included
2019. According to the population size, which was 750 people, the sample size people who have
traveled as medical
was calculated tourists
as 256 from
people, basedIran to Cochran
on the other countries.
method. The This statistic
statistical was based on
population
included from
information peoplethe
whoMinistry
have traveled as medical
of Health tourists
of Iran fromfrom Iran to other
2019.The countries.
analysis wasThis
performed
statistic was based on information from the Ministry of Health of Iran
in two parts. In the first part, fuzzy SWARA was used to weigh the specified criteria from 2019.The
analysis was performed in two parts. In the first part, fuzzy SWARA was used to weigh
and sub-criteria; and in the second part, the PROMETHEE method was used to prioritize
the specified criteria and sub-criteria; and in the second part, the PROMETHEE method
eightwas
countries with the highest level of medical tourism, selected based on the indicators
used to prioritize eight countries with the highest level of medical tourism, selected
and opinions
based on the indicatorsThe
of experts. and executive
opinions offramework
experts. Theofexecutive
the research is presented
framework of the in the
following Figure
research 1.
is presented in the following Figure 1.
Figure 1. The 1.executive

Figure framework
The executive ofof
framework the
theresearch. Source:Author’s
research. Source: Author’sownown contribution.
contribution.
There is a limit to the use of the PROMETHEE technique to compensate for the
weakness of one criterion or the strength of another. Therefore, an ideal alternative
There is a limit to the use of the PROMETHEE technique to compensate for the
weakness of one criterion or the strength of another. Therefore, an ideal alternative should
obtain the minimum of all criteria. In addition, the PROMETHEE method is easily able
to use criteria with different measurement scales (no need to normalize the scale of the
criteria) and defines the criteria for the six separate preference functions information.
Therefore, in multi-criteria decision-making such as PROMETHEE, which usually has
different measurement criteria, there was a strong point for decision-making.
The reasons for using SWARA approach were as follows: Firstly, SWARA’s approach
is different from other similar methods, such as ANP and AHP. SWARA gives the chance
to decision makers to select their priority based on the current situation of alternatives.
Secondly, the role of the experts is very important in this approach. At the end, it should be
added that SWARA has the advantage of a more logical calculation of weights and relative
importance of criteria [84].
3.1. Fuzzy SWARA

The use of fuzzy numbers in analysis is due to uncertainty in decisions [85]. The use
of fuzzy SWARA is less common in decision-making literature [86]. Some researchers have
been working on this in recent years [87,88]. Crisp SWARA, developed by Keršuliene et al. [89],
is inadequate to handle uncertainty, so the fuzzy extension of this method was developed.
The reason for using the fuzzy SWARA approach was the inherent uncertainty of deciding
on medical tourism destinations. Also, due to the qualitative nature of most of the criteria
and the ease of collecting the opinions of decision makers, a SWARA fuzzy approach was
used. Using a fuzzy approach brings the results closer to the real world.
The process of determining the relative weight of the criteria using the SWARA
method with the following steps can be shown in detail [90]:
We arranged the criteria in descending order.
According to the Table 2, we determined the relative importance of factor j compared
to the previous factor (j-1), which was of higher importance.
Table 2. Fuzzy and linguistic values [91].
Linguistic Scale Response Scale

Equally Important (1,1,1)
Moderately Less Important (2/3,1,3/2)
Less Important (2/5,1/2,2/3)
Very Less Important (2/7,1/3,2/5)
Much Less Important (2/9,1/4,2/7)
∼
1. Calculate the value of k j using Equation (1). It should be noted that the fuzzy
parameters are shown with the symbol ~.
∼
 
∼ 
1j = 1

kj = ∼ (1)
 S + 1j > 1 
j
∼
where k j is the value of the coefficient of comparative importance.
∼
2. Calculate the value of q j using Equation (2):
 
 1j = 1 
∼
 ∼

qj = k j −1 (2)
 ∼ j>1 
kj
 
∼
where q j is value of the fuzzy weights of the criteria.
3. Calculate the weight of the criteria using Equation (3),
∼
where n is the number of criteria and W j is the weight of the criterion j:
∼
∼ qj
Wj = n ∼ . (3)
∑ qk
k =1
3.2. PROMETHEE
The PROMETHEE method uses outranking method relation between alternatives
to solve problems that have a finite action and need to be sorted considering different
criteria and different units [92,93]. Unlike other ranking methods, which apply the same
ranking scale and preference function (PF) in the ranking process, PROMETHEE usually
uses different preference functions to define different decision attributes according to their
different characteristic [94,95]. The procedure of PROMETHEE is constituted by four steps:
Calculating the deviations based on comparison between two alternatives with respect
to j the criterion using Equation (4):
d j ( a, b) = f j (a) − f j (b) j = 1, 2, . . . , k (4)
where j denotes the jth criterion k stands for the finite number of criteria. d j ( a, b) is the
difference between the evaluations of two actions (a) and f j (b)) for criterion.
Applying the preference function using Equations (5) and (6):

Pj ( a, b) = Fj d j ( a, b)] j = 1, 2, . . . , k (5)
0 ≤ Pj ≤ 1 j = 1, 2, . . . , k (6)
where Pj ( a, b) expresses the preference for alternative a with regard to alternative b on the
jth criterion.
Calculating a global preference index. The overall multi-criteria preference list π ( a, b)
is denoted as Equation (7):
k
π ( a, b) = ∑ Wj Pj (a, b) j = 1, 2, . . . , k (7)
j =1
where w j represents the weight of the criterion j.

Calculating the outranking flows. The outgoing flow phi+ , which defines the outrank-
ing of alternative a (how a dominates all the other alternatives), and the incoming flow
phi−, which indicates the outranked character of alternative a (how a is dominated by all
the other alternatives), can be represented as follows [96]:
+( a)= ∑ π ( x,a)
phi x∈ A , (8)
−( a)= ∑ π ( a,x )
phi x∈ A (9)
where a denotes the alternative set and x represents all alternatives except alternative a.
The net flow phi ( a), which is defined by Equation (10), expresses the overall preferred
degree of alternative a. Higher value of phi ( a) means a better performance of alternative a.
phi ( a) phi. (10)

4. Results and Discussion

After conducting the research steps, the specified criteria are presented in Table 3. To
select these criteria, the opinions of five experts with more than 20 years of experience in
the field of medical tourism were used. These experts were among the most experienced
surgeons in the country who have been working in the field of medical tourism in various
countries for many years. These people were among the most experienced and specialized
university people in the field of medical tourism in the country. These experts were selected
only to select criteria and the questionnaire was filled by medical tourists.
Table 3 shows the criteria used to select a medical tourism destination.
The options (alternatives) considered by experts were Brazil, Costa Rica, India, Mexico,
Panama, Singapore, Taiwan and Malaysia. The reasons were the high incomes and foreign
exchange earnings that the medical tourism of these countries had, and many governments
are trying to strengthen this industry in their country.
The global and local weights of the considered criteria and sub-criteria obtained by
fuzzy SWARA approach are shown in Table 4:
Table 5 shows the output results of Visual PROMETHEE software. The official site
and the tutorial version of the software can be downloaded from http://www.promethee-
gaia.net. This table shows the values of Phi (a), Phi ( a)+ and Phi ( a)− . The value of Phi (a)
is equal to the difference between the values of Phi ( a)+ and Phi ( a)− .
The GAIA plane is the principal plane obtained by applying a principal components
analysis to the set of actions in this space. Moreover, a GAIA plane represents a focal-plane
assembly and has a major applicability in space applications.
In the GAIA plane, the following relationships hold:
1. The longer the axis of a criterion is, higher the distinguishing power of that criterion
will be.
2. The criteria that have similar preferences are shown by almost parallel axes.
3. The criteria that have conflicting preferences are shown in opposite directions.
4. The criteria that do not communicate with each other (in terms of the preference) are
perpendicular to each other.
5. The similar actions are shown by points close to each other.
6. Suitable actions on a criterion are shown by points in the direction of the given criteria.
Table 3. Identified sustainable criteria for choosing a medical tourism destination.
No Criteria Sustainability Dimension Sub-Criteria Definition

Number of doctors and nurses for fast and far from
Staff quantity (c1)
expectation services
Increase the operational capacity of physicians and nurses
Staff quality (c2)
in serving patients
1 Abilities of skilled staff Social
Up-to-date staff (c3) Develop staff information capacity about patients
Specialized staff (c4) Use of experienced specialists and trained personnel
Familiarity of staff with foreign languages (c5) Familiarity with different dialects and languages
Observing international standards (c6) Utilizing the highest standards in providing services
Performing various medical and care services with
Using experienced professionals to treat tourists (c7)
international specialists
2 Applied medical equipment Utilizing the highest equipment and familiar with new
Using modern medical equipment and procedures (c8)
methods for treating patients
Paying attention to the appropriate space to introduce the
Describe the different sections for reception and service
hospital to tourists (c9)
Providing extensive advertising to introduce the hospital to New methods of advertising to introduce medical centers
tourists (c10) and medical services
Organizing and providing the most effective treatment plan to
Economic Use international doctors and introduce their programs
the international medical community (c11)
3 Marketing capability
Spending on marketing and attracting tourists (c12) Increase advertising costs
Use the potential and effective capacity of specialized
Hiring specialized staff for planning and advertising (c13)
forces to attract tourists
Receiving minimum medical expenses from tourists (c14) Receiving minimum medical expenses from tourists
Spending the least possible time for hospitalizing tourists (c15) Spending the least possible time for hospitalizing tourists
4 Type of service provided Diversity of medical services (c16) Diversity of medical services
Minimizing bureaucracy to accept patients (c17) Minimizing bureaucracy to accept patients
Friendly behavior of medical staff toward tourists (c18) Friendly behavior of medical staff toward tourists
Table 3. Cont.
No Criteria Sustainability Dimension Sub-Criteria Definition

Having a special website to introduce the diversity and A specialized and special website to introduce all kinds of
environmental-therapeutic attractions of the destination medical tourism attractions with good and easy access and
country (c19) transparent information
Application of information
5 and communications Environmental Coordinating the patient’s medical information with the
Identify the condition and situation of the patient in the
technology hospital of the country of origin to inform about the types of
country of origin and check his or her opinion and interest
special environmental attractions, taking into account the
in having all kinds of facilities in the destination country
physical and mental conditions (c20)
Table 4. The criteria and sub-criteria obtained by fuzzy SWARA.
Main Criteria Wj Sub-Criteria bj kj qj Wj Local Weight Global Weight

c2 (1, 1, 1) (1, 1, 1) (0.360, 0.466, 0.420) 0.415 0.073
c3 (0.4, 0.5, 0.667) (1.4, 1.5, 1.667) (0.714, 0.666, 0.599) (0.257, 0.310, 0.252) 0.274 0.0482
Abilities of skilled staff 0.176 c4 (0.23,1.5,0.465) (1.23, 2.5, 1.465) (0.580, 0.266, 0.408) (0.209, 0.124, 0.171) 0.169 0.0297
c1 (1, 1, 1) (2, 2, 2) (0.29, 0.133, 0.204) (0.104, 0.062, 0.085) 0.084 0.0147
c5 (0.540, 0.650, 0.23) (1.54, 1.65, 1.23) (0.188, 0.08, 0.165) (0.067, 0.037, 0.069) 0.058 0.0102
c7 (1, 1, 1) (1, 1, 1) (0.429, 0.579, 0.456) 0.489 0.1134
c8 (0.53, 1.74, 0.37) (1.53,2.74,1.37) (0.653, 0.364, 0.729) (0.280, 0.210, 0.332) 0.273 0.0633
Applied medical equipment 0.232
c6 (0.444, 0.5, 1.36) (1.444, 1.5, 2.36) (0.452, 0.242, 0.308) (0.193, 0.14, 0.14) 0.159 0.0368
c9 (1, 1, 1) (2, 2, 2) (0.226, 0.121, 0.154) (0.096, 0.070, 0.070) 0.079 0.0183
c11 (1,1,1) (1,1,1) (0.450, 0.496, 0.537) 0.495 0.0534
c12 (0.5, 0.66, 1.12) (1.5, 1.66, 2.12) (0.666, 0.602, 0.471) (0.299, 0.298, 0.252) 0.284 0.0306
Marketing capability 0.108
c13 (1.04, 1.5, 1) (2.04, 2.5, 2) (0.326, 0.24, 0.235) (0.146, 0.119, 0.126) 0.131 0.0141
c10 (0.42, 0.373, 0.5) (1.42, 1.373, 1.5) (0.229, 0.174, 0.156) (0.103, 0.086, 0.083) 0.090 0.0097
c14 (1, 1, 1) (1, 1, 1) (0.459, 0.503, 0.52) 0.495 0.1955
c16 (1, 1, 1) (2, 2, 2) (0.5, 0.5, 0.5) (0.229, 0.251, 0.26) 0.247 0.0975
Type of service provided 0.395 c15 (0.63, 1.2, 1) (1.63, 2, 2) (0.306, 0.25, 0.25) (0.14, 0.125, 0.13) 0.132 0.0521
c17 (0.444, 0.76, 0.1.32) (1.444,1.76,2.32) (0.211, 0.142, 0.107) (0.097, 0.071, 0.055) 0.075 0.0296
c18 (0.333, 0.5, 0.666) (1.333, 1.5, 1.666) (0.158, 0.094, 0.064) (0.072, 0.047, 0.033) 0.051 0.0201
Application of information and c19 (1, 1, 1) (1, 1, 1) (0.666, 0.666, 0.666) 0.666 0.0592
0.089
communications technology c20 (1, 1, 1) (2, 2, 2) (0.5, 0.5, 0.5) (0.333, 0.333, 0.333) 0.334 0.0297
Table 5. Results of PROMETHEE calculation.
Actions Phi Phi+ Phi−

India 0.1396 0.5213 0.3818
Malaysia 0.1128 0.4905 0.3778
Panama 0.0976 0.4971 0.3995
Mexico 0.0790 0.4854 0.4064
Singapore 0.0096 0.4566 0.4470
Taiwan −0.0442 0.4188 0.4630
Brazil −0.1747 0.3629 0.5375
Costa Rica −0.2196 0.3405 0.5601
Table 6 shows the global decision matrix obtained by the experts’ opinions.
Table 6. Global decision matrix.
A/C C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 C16 C17 C18 C19 C20
A1 Vb A A A A G A B A G Vg Vg Vg A B G G A Vb Vg
A2 Vg A A Vg Vg G A Vg B B A Vg G G G G B B G B
A3 G G A G G A A Vb B B Vg Vb A Vg G G Vg B G G
A4 B A A A A B G Vb Vg B A A Vg Vb Vb A Vg G G B
A5 A G A Vg A G B A Vg Vg G B Vg G B Vg G Vg G Vg
A6 G A G G A B B Vg Vb Vg A B Vb A G B A G B Vb
A7 A A G A A A A Vg Vb A Vb B Vb G Vg B B A A Vg
A8 G A G B A A A Vb Vg A B G Vb G Vb B A B B Vb
Source: Author’s own contribution. Note: Vb: Very bad, B: Bad, A: Average, G: Good, Vg: Very good, A1: Panama, A2: Malaysia, A3:
Mexico, A4: Singapore, A5: India, A6: Taiwan, A7: Brazil, A8: Costa Rica.
Table 7 shows the numerical values of the linguistic terms.
Table 7. Numerical values of the linguistic terms.
Linguistic Term Value

Vb 9
B 7
A 5
G 3
Vg 1
Table 8 presents the type of optimization of the sub-criteria and the preference func-
tions as follows:
Table 8. Type of optimization of the sub-criteria and the preference functions.
A/C c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20
Type Max Max Max Max Max Max Max Max Max Max Max Max Max Min Min Max Min Max Max Max
PF Lin U U U U U U U U U U U U Us Us U U U U U
Source: Author’s own contribution. U: Usual, Us: U-shape, Vs: V-shape, L: Level, Lin: Linear, G: Gaussian.
Table 8. Type of optimization of the sub-criteria and the preference functions.
A/C c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20
Typ Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Mi Mi Ma Mi Ma Ma Ma
Sustainability 2021, 13, 683 e x x x x x x x x x x x x x n n x n x x x 19 of 32
PF Lin U U U U U U U U U U U U Us Us U U U U U
Source: Author’s own contribution. U: Usual, Us: U-shape, Vs: V-shape, L: Level, Lin: Linear, G:
Gaussian.
According to Table 4, the GAIA plane is shown in Figure 2. This figure is the output
According
of the Visual to Table 4, the
PROMETHEE GAIA plane
software. Dueistoshown in Figure 2. This figureofisthe
the multidimensionality the GAIA
output plane,
theofleft-side
the Visual PROMETHEE
plane shows the software. Due to the multidimensionality
U–V dimension, and the right-sideofplanethe GAIA
shows plane,
the U–W
the left-side
dimension plane2).
(Figure shows the U–V
The red dimension,
axis is called theand the right-side
decision brain andplane shows
shows thethe U–W
preference of
thedimension (Figure 2).
decision makers. AsThe
canred
be axis
seenisincalled the decision
the left-side brain
plane, andisshows
India closerthe
to preference
the criteria than
of the decision makers. As can be seen in the left-side plane, India is closer to the criteria
other countries, and Costa Rica and Brazil are the farthest. According to this plane, criteria
than other countries, and Costa Rica and Brazil are the farthest. According to this plane,
c8 and c15 are in the same direction and also, criteria c7 and c9 are in the same direction.
criteria c8 and c15 are in the same direction and also, criteria c7 and c9 are in the same
This indicates
direction. that
This these criteria
indicates have
that these similar
criteria objectives.
have The proximity
similar objectives. of c6, c18ofand
The proximity c6, c10 to
India indicates that it performed well in terms of these criteria.
c18 and c10 to India indicates that it performed well in terms of these criteria.
Sustainability 2021, 13, x FOR PEER REVIEW 18 of 32
Figure
Figure 2. GAIA
2. GAIA planeanalysis.
plane analysis. Source:
Source:Author’s
Author’sown contribution.
own contribution.
The
The resultsofofthe
results the right-side
right-side plane
planeindicate
indicatethat thethe
that decision brainbrain
decision is inclined toward
is inclined toward
India, and according to this plane, India was selected as option 1.
India, and according to this plane, India was selected as option 1. Taiwan also performed Taiwan also
performed well in terms of c8 and c4, while it performed poorly in terms of c3 and c7.
well in terms of c8 and c4, while it performed poorly in terms of c3 and c7. The gap between
The gap between India and Costa Rica in this plane shows the difference between the
India and Costa Rica in this plane shows the difference between the criteria of these two
criteria of these two countries and also their ranking.
countries and also their ranking.
Table 9 shows the ranking of medical tourism destinations. This table is the output
of Table 9 shows
the Visual the ranking
PROMETHEE of medical
software and thetourism destinations.
PROMETHEE ThisAstable
V method. is the
can be seenoutput
in of
thethe
Visual PROMETHEE
PROMETHEE software
V results, Costaand thewas
Rica PROMETHEE V method.
the last option As can be
for a medical seen in the
tourism
PROMETHEE
destination andV results,
Brazil wasCosta Rica was
the seventh the last
option. option
Taiwan andforSingapore
a medical tourism
also rankeddestination
sixth
and fifth, respectively. So the global ranking was India, Malaysia, Panama, Mexico,
Singapore, Taiwan, Brazil, and Costa Rica, respectively. The optimal results of the
objective function of the PROMETHEE V approach were 0.6453 (0.2522 + 0.2982 + 0.0636
+ 0.0312).
From the PROMETHEE 2 method, which is a complete ranking, we got a complete
and Brazil was the seventh option. Taiwan and Singapore also ranked sixth and fifth,
respectively. So the global ranking was India, Malaysia, Panama, Mexico, Singapore,
Taiwan, Brazil, and Costa Rica, respectively. The optimal results of the objective function of
the PROMETHEE V approach were 0.6453 (0.2522 + 0.2982 + 0.0636 + 0.0312).
Table 9. PROMETHEE V global ranking.
Actions Net Flow Optimal

Malaysia 0.2522 yes
Taiwan −0.0726 no
Brazil −0.3157 no
Mexico −0.0619 no
Panama 0.2982 yes
India 0.0636 yes
Costa Rica −0.1951 no
Singapore 0.0312 yes
Total 0.6453
From the PROMETHEE 2 method, which is a complete ranking, we got a complete

summary of the options ranking. But PROMETHEE V also includes restrictions on cri-
teria; for example, if we have a measure called cost or budget, we can create a limit on
this criterion.
Figure 3 shows the GAIA web plane. This figure is the output of the Visual PROMETHEE
software. This plane shows the importance and quality of a criterion based on the desired
option. The left-side plane shows the criteria for India. According to this plane, India
based on the desired option. The left-side plane shows the criteria for India. According
performed well in terms of “paying attention to the appropriate space to introduce the
to this plane, India performed well in terms of “paying attention to the appropriate
hospital to tourists (c9)” and “providing extensive advertising to introduce the hospital to
space to introduce the hospital to tourists (c9)” and “providing extensive advertising to
tourists (c10).” In addition, this country was able to satisfy tourists in terms of “friendly
introduce the hospital to tourists (c10).” In addition, this country was able to satisfy
behavior of medical staff towards tourists (c18),” ”having a specific website for hospital
tourists in terms of “friendly behavior of medical staff towards tourists (c18),” ”having a
introduction (c19),” and “specialized staff (c4).”
specific website for hospital introduction (c19),” and “specialized staff (c4).”
Figure 3. GAIA
Figure 3. GAIA web.
web. Source:
Source: Author’s
Author’s own
own contribution.
contribution.
The right-side plane shows the quality of the criteria for Malaysia. This country
performed well in terms of “staff quantity (c1),” “familiarity of staff with foreign
languages (c5),” “using modern medical equipment and procedures (c8),” and
“spending on marketing and attracting tourists (c12).” This country was weak in terms
of “providing extensive advertising to introduce the hospital to tourists (c10)” and
The right-side plane shows the quality of the criteria for Malaysia. This country
performed well in terms of “staff quantity (c1),” “familiarity of staff with foreign languages
(c5),” “using modern medical equipment and procedures (c8),” and “spending on market-
ing and attracting tourists (c12).” This country was weak in terms of “providing extensive
advertising to introduce the hospital to tourists (c10)” and “friendly behavior of medical
staff towards tourists (c18)”.
Figure 4 shows the walking weights chart. This figure is the output of the Visual
PROMETHEE software. This figure shows the sensitivity analysis of medical tourism
destinations in terms of the criteria considered. The right-side chart shows the sensitivity
analysis based on the “staff quantity (c1).” As can be seen by the increase in the weight of
this criterion up to 50% and keeping the weights of the other criteria constant, Malaysia
was selected as the top medical tourism destination, followed by Mexico in second rank. It
indicates that the two countries were in a good condition in terms of staff quantity. Costa
Rica, Taiwan, India, Singapore, Panama, and Brazil ranked third to eighth, respectively.
According to this chart, Brazil was weaker than other countries in terms of staff quantity
and needs to improve.
Figure
Figure 4.
4. Walking weights. Source:
Walking weights. Source: Author’s
Author’s own
own contribution.
contribution.
The left-sidechart
The left-side chartshows
shows thethe sensitivity
sensitivity analysis
analysis of medical
of medical tourism
tourism destinations
destinations based
based
on theon the “up-to-date
“up-to-date staff With
staff (c3).” (c3).” aWith
50% aincrease
50% increase
in the in the weight
weight of thisof this criterion,
criterion, Costa
Costa
Rica was Ricachosen
was chosen
as theas thecountry.
best best country. It indicates
It indicates thatcountry
that this this country performed
performed very very
well
well
in thisin regard.
this regard. Taiwan,
Taiwan, Panama, Panama, Singapore,
Singapore, and Mexico
and Mexico werewere also ranked
also ranked secondsecond to
to fifth.
fifth. Countries
Countries that performed
that performed poorly poorly
in thisinregard
this regard include
include Brazil,Brazil,
India, India, and Malaysia,
and Malaysia, which
which
rankedranked fifth toThese
fifth to eighth. eighth. These countries
countries need to make need to make
efforts effortsthis
to improve to improve
criterion. this
criterion.
The following Figure 5 shows the PROMETHEE rainbow chart. The criteria with
positive
The net Phi values
following are at
Figure 5 the
shows top the
of the chart and therainbow
PROMETHEE criteria with negative
chart. net Phi
The criteria are
with
displayed at the bottom of the chart. India had the best performance
positive net Phi values are at the top of the chart and the criteria with negative net Phi compared to other
countries
are displayed in terms
at theofbottom
criteriaof c9,thec13, c18, c16,
chart. Indiawhile it did
had the notperformance
best perform well in terms to
compared of
criteriacountries
other c14, c12, c15 and c5.
in terms ofMalaysia
criteria c9,hadc13,the best
c18, performance
c16, while itindidterms
notofperform
criterionwell
c8 and
in
the worst
terms performance
of criteria in terms
c14, c12, c15 and of criterion c17. Inhad
c5. Malaysia Panama,
the bestc13 performance
was the best and c19 was
in terms of
the worstc8criterion.
criterion and the worst performance in terms of criterion c17. In Panama, c13 was the
best and c19 was the worst criterion.
Figure 5. PROMETHEE rainbow. Source: Author’s own contribution

Figure 5. PROMETHEE rainbow. Source: Author’s own contribution
Mexico
Mexico and and Singapore
Singaporehad hadthe thebest
bestperformance
performance in in terms
terms of criteria
of criteria c11 c11
and and
c13, c13,
and
and the worst performance in terms of criteria c12 and c14,
the worst performance in terms of criteria c12 and c14, respectively. Taiwan had the respectively. Taiwan hadbestthe
best performance in terms of criterion c8 and the worst performance
performance in terms of criterion c8 and the worst performance in terms of criterion c13. in terms of criterion
c13. Brazil
Brazil performed
performed wellwell
onlyonly in terms
in terms of criteria
of criteria c15,c20,
c15, c8, c8, c14,
c20, c6,
c14,and
c6, c19.
and c19.
In the Inend,
the
end,
CostaCosta
Rica hadRica thehad
bestthe best performance
performance in terms ofincriterion
terms c9 of and
criterion
the worstc9 and the worst
performance in
performance in terms
terms of criterion c13. of criterion c13.
In
In 2019,
2019, 13,232
13,232 trips
trips were
were made made from from IranIran with
with thethe intention
intention of of medical
medical tourism.
tourism.
Among the the trips
tripsmademadewere were4398 4398trips
trips to India. There were also 3425 trips
to India. There were also 3425 trips to Malaysia and to Malaysia
and
21782178
trips trips to Panama.
to Panama. The shares
The shares of Mexico,
of Mexico, Singapore,
Singapore, and Taiwanand Taiwan
for medical for medical
tourism
tourism
were 1011, were
938,1011, 938,trips,
and 755 and respectively.
755 trips, respectively.
There were There also 417 were
tripsalso 417 trips
to Brazil and to 110Brazil
trips
and 110 trips
to Costa Rica to CostaAccording
[97,98]. Rica [97,98]. to According
the statistics toand
the their
statistics and theirwith
comparison comparison
the results withof
this study,
the resultsthe ofaccuracy of ranking
this study, tourism destinations
the accuracy of rankingfrom the perspective
tourism destinations of the
fromIranian
the
people was confirmed.
perspective of the Iranian The people
results of wastheconfirmed.
real statistics Thealso showed
results of that Indiastatistics
the real was selected also
as the most popular tourist destination by Iranians.
showed that India was selected as the most popular tourist destination by Iranians.
In order
In order to toverify
verifythe themodel,
model, thetheproposed
proposed model
modelwaswas compared
compared withwiththe fuzzy AHP
the fuzzy
and fuzzy
AHP VIKOR
and fuzzy approaches.
VIKOR approaches.
Table 10
Table 10showsshows the the
results of comparing
results of comparing the rankingthe of medicalof
ranking tourism
medicaldestinations
tourism
with differentwith
destinations approaches.
differentComparing
approaches.the results of the
Comparing the proposed
results of approach
the proposed with approach
the fuzzy
AHP the
with approach
fuzzy shows the difference
AHP approach showsbetween the 5th andbetween
the difference 6th (Taiwan and and
the 5th Singapore) ranks.
6th (Taiwan
Comparing the results of the proposed approach with the
and Singapore) ranks. Comparing the results of the proposed approach with the fuzzy fuzzy VIKOR approach shows
the difference
VIKOR approach between
showsthe the3rd and 4th (Mexico
difference between and the Panama)
3rd and 4th ranks. It should
(Mexico be noted
and Panama)
that theIt weights
ranks. should be of the
notedcriteria
that the in VIKOR
weightswere obtained
of the criteriafrom fuzzy were
in VIKOR SWARA. Due to
obtained the
from
closeness
fuzzy of the ranking
SWARA. Due to the of the fuzzy AHP
closeness of theand fuzzy VIKOR
ranking approaches
of the fuzzy AHP and withfuzzy
the proposed
VIKOR
approach, the
approaches accuracy
with of the proposed
the proposed approach, model thewas proved of
accuracy (Appendix A and ??).
the proposed model was
proved (Appendix A and Appendix B).
Table 10. Verification of the results.

nability 2021, 13, x FOR PEER REVIEW 22 of 32

Table 10. Verification of the results.
FUZZY FUZZY
Rank Proposed Approach
FUZZY AHP FUZZY VIKOR
Rank Proposed Approach
Rank 1 AHP
India India VIKOR India
Rank 1 India Rank 2 India
Malaysia Malaysia India Malaysia
Rank 2 Malaysia Malaysia Malaysia
Rank 3 Panama Panama Mexico
Rank 3 Panama Panama Mexico
Rank 4 Mexico Mexico Panama
Rank 4 Mexico Mexico Panama
Rank 5 Singapore Taiwan Taiwan
Rank 5 Singapore Taiwan Taiwan
Rank 6 Taiwan Rank 6 Taiwan
Singapore Singapore
Singapore Singapore
Rank 7 Brazil Rank 7 Brazil
Brazil Brazil Brazil Brazil
Rank 8 Costa Rica Rank 8 Costa
Costa RicaRica Costa Rica
Costa Rica Costa Rica
Source: Author’s
Source: Author’s own
own contribution.
contribution.
Figure 6 also shows

Figurethe weight
6 also comparisons
shows the weightof the criteria of
comparisons in the criteria
fuzzy SWARA and SWARA and
in the fuzzy
fuzzy AHP methods:
fuzzy AHP methods:
0.25
0.2
0.15
fuzz
0.1 y
swa
ra
0.05
0
c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16 c17 c18 c19 c20
Figure 6. Comparison
Figure of criteria
6. Comparison weightsweights
of criteria in fuzzyinAHP and
fuzzy fuzzy
AHP andSWARA. Source: Source:
fuzzy SWARA. Author’s own contribution.
Author’s own
contribution.
For comparing the results with the previous one obtained in the literature, Levary et al. [57]
was selected.
For comparing the results Thewith
results
the of Levaryone
previous et al. [57] also
obtained in proved the results
the literature, of our research.
Levary
Levary et al. [57] also selected India as the first destination.
et al. [57] was selected. The results of Levary et al. [57] also proved the results of ourTherefore, comparing the
research. Levary et al. [57] also selected India as the first destination. Therefore, this research.
results of other researches in the literature review also proved the results of
comparing the resultsFigure 7 shows
of other the results
researches of literature
in the the criteria sensitivity
review analysis.
also proved theFor this purpose, the
results
values
of this research. of the criteria weights were changed and changes in the alternative were observed.
The horizontal axis shows the criteria and the vertical axis shows the percentage of changes
Figure 7 shows the results of the criteria sensitivity analysis. For this purpose, the
in the criteria weights. The blue lines indicate the upper limit and the red lines the lower
values of the criteria weights were changed and changes in the alternative were
limit. As can be seen from the figure, for example, the upper limit of the first criterion
observed. The horizontal axis shows the criteria and the vertical axis shows the
change for that alternative ranking remains constant at 16% and the lower limit is 10%.
percentage of changes in the criteria weights. The blue lines indicate the upper limit and
the red lines the lower limit. As can be seen from the figure, for example, the upper limit
of the first criterion change for that alternative ranking remains constant at 16% and the
lower limit is 10%.
bility 2021,Sustainability
13, x FOR PEER REVIEW
2021, 13, 683 23 of 32 24 of 32
20
18
16
14
12
% Change
10
8 Upper limit
Lower limit
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Criteria
Figure 7. The sensitivity of changes in the criteria. Source: Author’s own contribution.
Figure 7. The sensitivity of changes in the criteria. Source: Author’s own contribution.
5. Conclusions
5. Conclusions Health tourism represents one of the fastest growing segments in the tourism industry.
Tourism as well as medical tourism can be sustainable if developed and managed, consider-
Health tourism represents one of the fastest growing segments in the tourism
ing both tourists and communities. This can be achieved through community engagement,
industry. Tourism as well as medical tourism can be sustainable if developed and
congestion management, reduction of seasonality, careful planning that respects the limits
managed, considering both tourists and communities. This can be achieved through
of capacity and the specificities of each destination, and product diversification.
community engagement, congestion management, reduction of seasonality, careful
In this study, using a combined fuzzy SWARA-PROMETHEE approach, famous coun-
planning that respects the limits of capacity and the specificities of each destination, and
tries in terms of medical tourism were ranked from the viewpoint of the Iranian people.
product diversification.
Therefore, five main criteria, including abilities of skilled staff, applied medical equipment,
In this study, using capability,
marketing a combined typefuzzy SWARA-PROMETHEE
of services provided, and application approach, famous and commu-
of information
countries in terms
nications technology along with 20 sub-criteria, were extracted. TheIranian
of medical tourism were ranked from the viewpoint of the weights of the criteria
people. Therefore,
werefive main criteria,
determined usingincluding
the fuzzy abilities
SWARA of skilled staff,
approach. Afterapplied
determiningmedicalthe weights of the
equipment, marketing
criteria, the capability, type of
medical tourism services were
destinations provided,
rankedand using application
the PROMETHEE of approach.
information and communications technology along with 20 sub-criteria, were extracted.
Identifying criteria related to sustainability in the subject of medical tourism destinations
The weights ofand the prioritizing
criteria were determined
medical tourism using the fuzzy
destinations SWARA
using these approach.
criteria areAfter
the contributions of
determining the weights of the criteria, the medical tourism
this paper. The results showed that India (Phi = 0.1396), Malaysia destinations were (Phi
ranked= 0.1128), Panama
using the PROMETHEE
(Phi = 0.0976),approach.
MexicoIdentifying
(Phi = 0.0790), criteria related (Phi
Singapore to sustainability
= 0.0096), Taiwan in the(Phi = −0.0442),
subject of medical
Brazil tourism
(Phi = − destinations
0.1747), andand Costa prioritizing
Rica (Phi =medical
−0.2196)tourism
were thedestinations
medical tourism priorities
using these criteria are the respectively.
for Iranians, contributionsThe of weights
this paper. The results
of criteria showed of
for “Abilities that Indiastaff,” “applied
skilled
(Phi = 0.1396), medical
Malaysia (Phi = 0.1128),
equipment,” Panamacapability,”
“marketing (Phi = 0.0976),
“type Mexico
of service (Phi = 0.0790),
provided,” and “application
Singapore (Phi of = information
0.0096), Taiwan and (Phi = −0.0442), Brazil
communications (Phi = −0.1747),
technology” were 0.176, and Costa
0.232, Rica0.395, and 0.089,
0.108,
(Phi = −0.2196)respectively.
were the The medical
resultstourism priorities analysis
of the sensitivity for Iranians,
showed respectively.
that Malaysia The
and Mexico were
weights of criteria for “Abilities of skilled staff,” “applied medical
in good condition in terms of staff quantity. Also, Brazil performed poorly in terms ofequipment,”
“marketing capability,” “typecompared
quantity staff of servicetoprovided,” and “application
other countries and needs to ofimprove.
information and of up-to-date
In terms
communications technology”
staff, Costa Ricawerehad 0.176,
the best 0.232, 0.108, 0.395,
performance andand 0.089, had
Malaysia respectively.
the worstThe performance. Sus-
results of the tainability
sensitivity isanalysis
a concept showed
that has that Malaysia
gained and popularity
increasing Mexico were in good
among consumers around
condition in terms of staff[99],
the world quantity.
and its Also, Brazil performed
implications for medical poorly in terms
tourism of quantityTo examine the
are growing.
staff comparedverification
to other countries and needs
of the proposed to improve.
approach, In terms
the results of up-to-date
were compared withstaff,
the fuzzy AHP and
Costa Rica had fuzzy
the VIKOR approaches. and
best performance Comparing
Malaysia the had
results
theof worst
the proposed approach with fuzzy
performance.
Sustainability isVIKOR approach
a concept that showed
has gained the difference
increasingbetween
popularitythe 3th
amongand 4th (Mexico and Panama)
consumers
around the world ranks.
[99],Also
and comparing
its implicationsthe results of thetourism
for medical proposed areapproach
growing. with fuzzy AHP approach
To examine
the verificationshowed the difference
of the proposed between
approach, thetheresults
5th and 6th (Taiwan
were compared andwithSingapore)
the fuzzy ranks. Due to the
AHP and fuzzycloseness
VIKOR of the rankingComparing
approaches. of the fuzzy the AHP and fuzzy
results of theVIKOR
proposedapproaches
approach with the proposed
with fuzzy VIKOR approach, the accuracy
approach showed of thedifference
the proposed betweenmodel was theproved.
3th and 4th (Mexico
Some empirical studies [100] revealed that the level of customer satisfaction is directly
correlated with their loyalty to the hospital, which is a prerequisite for the progress of the
health tourism market. According to certain researchers [101], interest in the preservation
of health and quality of life, which includes rest and recuperation, represents the major
tourist motivation. According to [102] the category of consumers in the health care system
includes the following two main subcategories: external customers, which includes patients,
family members of patients, and potential customers, and internal customers, which
includes employees and their employers. For instance, Malaysia is perceived as a hub
of medical tourism in Southeast Asia, while the health care travel industry is a private-
sector-driven [103]. The 1970s established certain Asian countries—Thailand, India and
Singapore—as the most popular medical tourism destinations [104].
According to Spulbar et al. (2019), a sustainable development-based approach has
significant implications for low and middle-income countries (emerging), considering their
main characteristic features such as: demographic dynamics, high degree of poverty, poor
quality education, migration, environmental degradation, social inequality, high levels
of urbanization, health system deficiencies, rapid technological change, and unsustain-
able economic growth [105]. Mehdiabadi et al. (2020) argued that considering current
challenges, the global economy is very dynamic and constantly changing, so innovation
and technological development represent essential aspects in regards to a sustainable
perspective [106].
The results of this study can help countries to strengthen their weaknesses. Also, iden-
tifying sustainable criteria for medical tourism destinations and prioritizing destinations
can help patients to choose destinations tailored to their needs. Sustainable criteria cover
all economic, social, and environmental dimensions. Therefore, identifying and prioritizing
criteria can help tourism destinations, for example, European or American countries, to
strengthen strengths and reduce their negative criteria. This study, like other studies, has
some limitations. One of the limitations of this research paper is the lack of access to more
extensive statistical databases. Also, due to the qualitative nature of most of the criteria,
including them in the questionnaire and converting them into quantitative criteria was
another limitation of this research. Other limitations include the use of fuzzy data and
their conversion to Crisp data. Finally, this study is limited to Iranians’ views on medical
tourism destinations. Despite the fact that it is a topic of interest, existing literature does
not contain many research studies on the linkage between health care aspects and tourism,
especially in the current context of the Covid-19 pandemic.
The following are recommended for future studies:
1. Prioritizing medical tourism destinations based on the viewpoints of the people living
in other countries, such as India, China, etc.;
2. Investigating the effect of different countries’ policies on their medical tourism, for
example, the policies adopted by countries regarding the COVID-19 outbreak;
3. Considering other criteria in addition to sustainability, such as resiliency, etc.;
4. Considering other uncertainty approaches, such as fuzzy type 2, stochastic, and scenario;
5. Predicting the demand for medical tourism in countries using sustainable criteria;
6. Prioritization of medical tourism destinations with regard to the occurrence of crises
such as the COVID-19 outbreak.
Author Contributions: All authors contributed equally to this research work. All authors discussed
the results and contributed to the final manuscript. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
1, 13, x FOR PEER REVIEW 26 of 32
Appendix A
Appendix A FUZZY AHP: In This Article, the Kutlu Gündoğdu and Kahraman (2019) Framework
Was Used to Introduce and Apply the Fuzzy AHP Method [107] According to the Following
FUZZY AHP: In This Article, the Kutlu Gündoğdu and Kahraman (2019) Framework Was Used to Introduce an
Table Captions:
Fuzzy AHP Method [107] According to the Following Table Captions:
Initial Comparison Matrices
Left Criteria Is Greater Right Criteria Is Greater

AMI VHI HI SMI EI SLI LI VLI ALI
A 1 B
A 1 C
A 1 D
A 1 E
A 1 F
A 1 G
A 1 H
B 1 C
B 1 D
B 1 E
B 1 F
B 1 G
B 1 H
C 1 D
C 1 E
C 1 F
C 1 G
C 1 H
D 1 E
D 1 F
D 1 G
D 1 H
E 1 F
E 1 G
E 1 H
F 1 G
F 1 H
G 1 H
Figure A1.
Figure Initial
A1. Comparison
Initial Matrices.
Comparison Source:
Matrices. Source:Author’s
Author’s own contribution.
own contribution.
Sustainability 2021,
Sustainability 2021, 13,
13, 683
x FOR PEER REVIEW 27 of 32 27 of 32
A B C D E F G H
A 0.500 0.400 0.400 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100
B 0.400 0.500 0.400 0.500 0.400 0.400 0.600 0.400 0.300 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100
C 0.400 0.600 0.300 0.400 0.600 0.300 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100
D 0.300 0.700 0.200 0.400 0.600 0.300 0.400 0.600 0.300 0.500 0.400 0.400 0.600 0.400 0.300 0.700 0.300 0.200 0.700 0.300 0.200 0.800 0.200 0.100
E 0.200 0.800 0.100 0.300 0.700 0.200 0.300 0.700 0.200 0.400 0.600 0.300 0.500 0.400 0.400 0.800 0.200 0.100 0.800 0.200 0.100 0.800 0.200 0.100
F 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.300 0.700 0.200 0.200 0.800 0.100 0.500 0.400 0.400 0.800 0.200 0.100 0.800 0.200 0.100
G 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.300 0.700 0.200 0.200 0.800 0.100 0.200 0.800 0.100 0.500 0.400 0.400 0.800 0.200 0.100
H 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.200 0.800 0.100 0.500 0.400 0.400
Crisp
Spherical Fuzzy Weights Crisp Weights
Weights
0.717 0.273 0.218 0.162 0.162
0.686 0.306 0.240 0.153 0.153
0.673 0.329 0.226 0.151 0.151
0.598 0.405 0.255 0.132 0.132
0.612 0.407 0.202 0.138 0.138
0.526 0.510 0.184 0.118 0.118
0.427 0.607 0.191 0.093 0.093
0.263 0.734 0.189 0.053 0.053
Consistency Ratio (CR) 0.2333 Compare with 0.1; It should be less than 0.1
FigureFigure
A2. Integrated Spherical
A2. Integrated Fuzzy Fuzzy
Spherical Comparison Matrix.Matrix.
Comparison Source:Source:
Appendix B Appendix B
FUZZY VIKOR: In this article,FUZZY VIKOR:

the Chang (2014)Inframework
this article,was
theused
Chang (2014) framework
to introduce and applywas
theused
fuzzytoVIKOR
introduce and [108]
method applyaccording
the fuzzytoVIKOR methodtable
the following [108]
captions:
according to the following table captions:
W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20
0.36 0.466
W1 0.42 0.257 0.31 W2 0.252 0.209 0.124
W3 0.171 0.104 0.062
W4 0.085 0.067 0.037 W5 0.069 0.429 0.579 W6 0.456 0.28 0.21 W7 0.332 0.193 0.014 W8 0.014 0.096 0.07 W9 0.07 0.45 0.496 W10 0.537 0.299 0.298W11 0.252 0.146 0.119W12 0.126 0.103 0.086W13 0.083 0.459 0.125 W14 0.13 0.229 0.071 W15 0.26 0.14 0.125
W16 0.13 0.097 0.071
W17 0.055 0.072 0.047W18 0.033 0.666 0.666W19 0.666 0.333 0.333W20 0.333
X1 0.42 0.257 0.31
0.36 0.466 X2 0.252 0.209 0.124X3 0.171 0.104 0.062
X4 0.085 0.067 0.037 X5 0.069 0.429 0.579 X6 0.456 0.28 0.21 X7 0.332 0.193 0.014 X8 0.014 0.096 0.07 X9 0.07 0.45 0.496 X10 0.537 0.299 0.298X11 0.252 0.146 0.119X12 0.126 0.103 0.086X13 0.083 0.459 0.125 X14 0.13 0.229 0.071 X15 0.26 0.14 X16
0.125 X17 0.055 0.072 0.047
0.13 0.097 0.071 X18 0.033 0.666 0.666X19 0.666 0.333 0.333X20 0.333
A 15.4000 19.0000
X1 22.6000 32.4000 42.0000
X2 51.6000 5.0000 8.6000
X3 12.2000 9.0000 12.7000
X4 16.4000 32.4000 42.0000
X5 51.6000 20.8000 24.4000
X6 28.0000 26.6000 32.2000
X7 37.8000 25.8000 31.1000
X8 36.4000 32.4000 42.0000
X9 51.6000 23.6000 28.1000
X10 32.6000 20.8000 24.4000
X11 28.0000 23.0000 27.0000
X12 31.0000 29.0000 36.6000
X13 44.2000 16.8000 21.8000
X14 26.8000 25.8000 32.4000
X15 39.0000 26.6000 32.8000
X16 39.0000 26.8000 33.6000
X17 40.4000 27.0000 33.1000
X18 39.2000 32.4000 42.0000
X19 51.6000 29.8000 38.8000
X20 47.8000
AB 6.2000 19.0000
15.4000 9.8000 22.6000
13.4000 32.4000
21.6000 42.0000
28.0000 51.6000
34.4000 16.6000
5.0000 20.2000 23.8000 15.8000
8.6000 12.2000 19.4000 16.4000
9.0000 12.7000 23.0000 27.0000 42.0000
32.4000 35.0000 51.6000
43.0000 20.8000
23.0000 24.4000
28.1000 28.0000
33.2000 26.6000
19.4000 32.2000
23.0000 37.8000
26.6000 25.8000
15.6000 31.1000
18.7000 36.4000
21.8000 32.4000
27.0000 42.0000
35.0000 51.6000
43.0000 23.6000
22.8000 28.1000
27.0000 32.6000
31.2000 20.8000
20.6000 24.4000
24.5000 28.0000
28.4000 23.0000
12.2000 27.0000
14.2000 31.0000
16.2000 29.0000
25.8000 36.6000
31.8000 44.2000
37.8000 16.8000
14.6000 21.8000
17.4000 20.2000 25.8000
26.8000 14.6000 32.4000
17.3000 39.0000
20.0000 26.6000
19.8000 25.1000 39.0000
32.8000 30.4000 26.8000
27.0000 33.6000
35.1000 40.4000
43.2000 27.0000
24.2000 33.1000
29.3000 39.2000
34.4000 32.4000
27.0000 42.0000
35.0000 51.6000
43.0000 29.8000
26.6000 38.8000
34.1000 47.8000
41.6000
BC 9.8000 13.5000
6.2000 17.2000 21.6000
9.8000 13.4000 30.0000 28.0000
38.4000 34.4000
46.8000 16.6000
10.0000 20.2000
13.8000 23.8000
17.6000 15.8000
10.4000 19.4000
14.1000 23.0000
17.8000 17.6000 35.0000
27.0000 23.3000 43.0000
29.0000 23.0000
24.2000 28.1000
28.6000 33.2000
33.0000 19.4000
18.6000 23.0000
22.1000 26.6000
25.6000 15.6000
27.8000 18.7000
34.5000 21.8000
41.2000 27.0000
21.6000 35.0000
28.0000 43.0000
34.4000 22.8000
19.0000 27.0000
22.4000 31.2000
25.8000 20.6000
14.8000 24.5000
17.8000 28.4000
20.8000 12.2000
17.2000 14.2000
20.4000 16.2000
23.6000 25.8000
24.2000 31.8000
28.9000 37.8000
33.6000 14.6000
18.0000 17.4000
25.1000 32.2000 14.6000
20.2000 17.6000 17.3000
21.4000 20.0000
25.2000 19.8000
15.8000 18.7000 30.4000
25.1000 21.6000 27.0000
12.8000 35.1000
16.6000 43.2000
20.4000 24.2000
20.0000 29.3000
26.2000 34.4000
32.4000 27.0000
21.6000 35.0000
28.0000 43.0000
34.4000 26.6000
19.0000 34.1000
24.8000 41.6000
30.6000
CD 5.2000 13.5000
9.8000 8.9000 17.2000
12.6000 30.0000
27.0000 38.4000
35.0000 46.8000
43.0000 10.0000
17.2000 13.8000
20.8000 17.6000
24.4000 10.4000
19.0000 14.1000
22.4000 17.8000
25.8000 0 23.3000
17.6000 0 29.0000
0 24.2000
15.0000 28.6000
18.3000 33.0000
21.6000 18.6000
17.8000 22.1000
21.7000 25.6000
25.6000 27.8000
19.2000 34.5000
22.9000 41.2000
26.6000 21.6000
16.2000 28.0000
21.0000 34.4000
25.8000 19.0000
21.4000 22.4000
25.6000 25.8000
29.8000 14.8000
24.4000 17.8000
29.1000 20.8000
33.8000 17.2000
17.0000 20.4000
20.7000 23.6000
24.4000 24.2000
17.0000 28.9000
20.3000 33.6000
23.6000 18.0000
18.0000 25.1000
21.2000 24.4000 17.6000
32.2000 26.4000 21.4000
32.1000 25.2000
37.8000 15.8000
20.8000 24.6000 21.6000
18.7000 28.4000 12.8000
18.0000 16.6000
21.9000 20.4000
25.8000 20.0000
16.2000 26.2000
21.0000 32.4000
25.8000 21.6000
16.2000 28.0000
21.0000 34.4000
25.8000 19.0000
14.2000 24.8000
18.3000 30.6000
22.4000
DE 14.8000
5.2000 18.6000 22.4000 27.0000
8.9000 12.6000 7.8000 35.0000
9.9000 43.0000
12.0000 17.2000
6.2000 20.8000
10.1000 24.4000
14.0000 19.0000
5.4000 22.4000
8.9000 25.8000
12.4000 16.2000
0 21.0000
0 25.8000 23.6000 18.3000
0 15.0000 28.1000 21.6000
32.6000 17.8000
13.0000 21.7000
16.8000 25.6000
20.6000 19.2000
20.8000 22.9000
24.6000 26.6000
28.4000 16.2000
10.8000 21.0000
14.0000 25.8000
17.2000 21.4000
26.2000 25.6000
31.3000 29.8000
36.4000 24.4000
15.4000 29.1000
18.7000 33.8000
22.0000 17.0000
16.2000 20.7000
19.4000 24.4000
22.6000 17.0000
11.4000 20.3000
13.6000 23.6000
15.8000 18.0000
19.0000 21.2000
22.7000 26.4000 26.4000
24.4000 13.0000 32.1000
17.1000 37.8000
21.2000 20.8000
10.8000 24.6000
12.6000 28.4000
14.4000 18.0000
10.8000 21.9000
15.4000 25.8000
20.0000 16.2000
10.8000 21.0000
14.0000 25.8000
17.2000 16.2000
10.8000 21.0000
14.0000 25.8000
17.2000 14.2000
9.0000 18.3000
11.8000 22.4000
14.6000
EF 4.4000 18.6000
14.8000 7.8000 22.4000
11.2000 7.8000
1.8000 9.9000
3.4000 12.0000
5.0000 14.0000 17.7000 14.0000
6.2000 10.1000 21.4000 10.4000
5.4000 14.1000 17.8000
8.9000 12.4000 9.2000 21.0000
16.2000 12.2000 25.8000
15.2000 23.6000
19.6000 28.1000
23.7000 32.6000
27.8000 13.0000
16.6000 16.8000
20.1000 20.6000
23.6000 20.8000
27.6000 24.6000
33.7000 28.4000
39.8000 10.8000
5.4000 14.0000
7.0000 17.2000
8.6000 26.2000
24.6000 31.3000
30.6000 36.4000
36.6000 15.4000
8.4000 18.7000
10.1000 22.0000
11.8000 16.2000
18.0000 19.4000
22.1000 22.6000
26.2000 11.4000
19.0000 13.6000
24.1000 15.8000
29.2000 19.0000
17.0000 22.7000
22.1000 27.2000 13.0000
26.4000 14.8000 17.1000
18.1000 21.2000
21.4000 10.8000
17.4000 12.6000
21.5000 14.4000
25.6000 10.8000
21.2000 15.4000
26.2000 20.0000
31.2000 10.8000
5.4000 14.0000
7.0000 17.2000
8.6000 10.8000
5.4000 14.0000
7.0000 17.2000
8.6000 9.0000
4.4000 11.8000
5.6000 14.6000
6.8000
FG 17.0000
4.4000 20.5000 24.0000 1.8000
7.8000 11.2000 0.6000 3.4000
1.3000 5.0000
2.0000 14.0000
6.0000 17.7000
9.8000 21.4000
13.6000 10.4000
4.6000 14.1000
7.7000 17.8000
10.8000 2.4000 12.2000
9.2000 3.6000 15.2000
4.8000 19.6000
21.6000 23.7000
25.6000 27.8000
29.6000 16.6000
19.8000 20.1000
23.8000 23.6000
27.8000 27.6000
20.4000 33.7000
24.3000 39.8000
28.2000 5.4000
0 7.00000 8.60000 24.6000
22.0000 30.6000
26.3000 36.6000
30.6000 14.6000 17.8000 11.8000
8.4000 10.1000 21.0000 18.0000
26.6000 22.1000
33.1000 26.2000
39.6000 19.0000
10.4000 24.1000
12.3000 29.2000
14.2000 17.0000
20.8000 22.1000
26.1000 31.4000 14.8000
27.2000 9.6000 18.1000
13.4000 21.4000
17.2000 17.4000
23.4000 21.5000
28.7000 25.6000
34.0000 21.2000
10.0000 26.2000
12.9000 31.2000
15.8000 5.4000
0.4000 7.0000
0.7000 8.6000
1.0000 5.4000
0 7.00000 8.60000 4.4000
1.4000 5.6000
2.1000 6.8000
2.8000
GH 8.4000 20.5000
17.0000 12.1000 24.0000
15.8000 0.6000
9.2000 12.9000
1.3000 16.6000
2.0000 10.0000
6.0000 13.5000 17.0000 4.6000
9.8000 13.6000 6.6000 10.4000 14.2000
7.7000 10.8000 2.4000 3.6000
2.4000 2.9000 4.8000
3.4000 21.6000
23.8000 25.6000
28.7000 29.6000
33.6000 19.8000
27.6000 23.8000
33.4000 27.8000
39.2000 20.4000
16.0000 24.3000
19.2000 28.2000
22.4000 3.2000
0 3.80000 4.4000 20.6000 26.3000
0 22.0000 24.3000 30.6000
28.0000 14.6000
10.0000 17.8000
13.4000 21.0000
16.8000 26.6000
14.8000 33.1000
19.9000 39.6000
25.0000 10.4000
22.8000 12.3000
28.2000 14.2000
33.6000 20.8000
21.2000 26.1000
26.7000 32.2000 9.6000
31.4000 4.0000 13.4000
5.4000 17.2000
6.8000 23.4000
16.0000 28.7000
19.3000 34.0000
22.6000 10.0000
8.4000 12.9000
11.2000 15.8000
14.0000 0.4000
1.2000 0.7000
1.7000 1.0000
2.2000 1.0000
0 1.40000 1.8000 3.0000 2.1000
0 1.4000 3.9000 2.8000
4.8000
H 8.4000 12.1000 15.8000 9.2000 12.9000 16.6000 10.0000 13.5000 17.0000 6.6000 10.4000 14.2000 2.4000 2.9000 3.4000 23.8000 28.7000 33.6000 27.6000 33.4000 39.2000 16.0000 19.2000 22.4000 3.2000 3.8000 4.4000 20.6000 24.3000 28.0000 10.0000 13.4000 16.8000 14.8000 19.9000 25.0000 22.8000 28.2000 33.6000 21.2000 26.7000 32.2000 4.0000 5.4000 6.8000 16.0000 19.3000 22.6000 8.4000 11.2000 14.0000 1.2000 1.7000 2.2000 1.0000 1.4000 1.8000 3.0000 3.9000 4.8000
Fuzzy Best Value F+ 17.000 20.500 24.000 32.400 42.000 51.600 5.000 8.600 12.200 4.600 7.700 10.800 32.400 42.000 51.600 24.200 28.700 33.600 27.600 33.400 39.200 27.800 34.500 41.200 32.400 42.000 51.600 26.200 31.300 36.600 24.400 29.100 33.800 12.200 14.200 16.200 29.000 36.600 44.200 14.600 17.400 20.200 4.000 5.400 6.800 26.600 32.800 39.000 8.400 11.200 14.000 27.000 33.100 39.200 32.400 42.000 51.600 29.800 38.800 47.800
Fuzzy Worst
Fuzzy Best ValValuueeF+F- 17.4.400000 20.7.850000 24.11.020000 32.0.640000 42.1.300000 51.2.060000 17.5.020000 20.8.680000 12.24.240000 19.4.600000 22.7.740000 10.25.880000 32.0400 42.0000 51.0600 24.15.200000 28.18.730000 33.21.660000 27.13.600000 33.16.480000 39.20.260000 27.15.860000 34.18.570000 41.21.280000 32.0400 42.0000 51.0600 26.19.200000 31.22.340000 36.25.680000 24.8.440000 29.10.110000 33.11.880000 12.26.260000 14.33.210000 16.39.260000 29.10.040000 36.12.630000 44.14.220000 14.21.620000 17.26.470000 20.32.220000 26.4.040000 32.5.440000 39.6.800000 26.10.680000 32.12.860000 39.14.040000 27.8.400000 11.35.210000 14.43.020000 27.0.400000 33.0.710000 39.1.020000 32.0400 42.0000 51.0600 29.1.480000 38.2.180000 47.2.880000
Fuzzy Worst Value F- 4.400 7.800 11.200 0.600 1.300 2.000 17.200 20.800 24.400 19.000 22.400 25.800 0 0 0 15.000 18.300 21.600 13.000 16.800 20.600 15.600 18.700 21.800 0 0 0 19.000 22.400 25.800 8.400 10.100 11.800 26.600 33.100 39.600 10.400 12.300 14.200 21.200 26.700 32.200 26.400 32.400 39.000 10.800 12.600 14.400 27.000 35.100 43.200 0.400 0.700 1.000 0 0 0 1.400 2.100 2.800
Figure
Figure A3. A3.Integrated IntegratedMatrix MatrixSource: Source:Author’s Author’sown owncontribution. contribution.
Figure A3. Integrated Matrix Source: Author’s own contribution.
W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20
0.36 0.466
W1 0.42 0.257 0.31
W2 0.252 0.209 0.124
W3 0.171 0.104 0.062
W4 0.085 0.067 0.037
W5 0.069 0.429 0.579
W6 0.456 0.28 0.21
W7 0.332 0.193 0.014
W8 0.014 0.096 0.07
W9 0.07 0.45 0.496
W10 0.537 0.299 0.298
W11 0.252 0.146 0.119
W12 0.126 0.103 0.086
W13 0.083 0.459 0.125
W14 0.13 0.229 0.071
W15 0.26 0.14 0.125
W16 0.13 0.097 0.071
W17 0.055 0.072 0.047
W18 0.033 0.666 0.666
W19 0.666 0.333 0.333
W20 0.333
X1 0.42 0.257
0.36 0.466 X2 0.252 0.209
0.31 X3 0.171 0.104
0.124 X4 0.085 0.067
0.062 X5 0.069 0.429
0.037 X6 0.456 0.28
0.579 X7 0.332 0.193
0.21 X8 0.014 0.096
0.014 X9 0.07 0.45
0.07 X10 0.537 0.299
0.496 X11 0.252 0.146
0.298 X12 0.126 0.103
0.119 X13 0.083 0.459
0.086 X14 0.13 0.229
0.125 X15 0.26 0.14
0.071 X16
0.125 X17 0.055 0.072
0.13 0.097 0.071 X18 0.033 0.666
0.047 X19 0.666 0.333
0.666 X20 0.333
0.333
A -0.2857 0.0765
X1 0.4388 -0.3765 X20 0.3765 -0.3711 X30 0.3711 -0.0849 0.2358
X4 0.5566 -0.3721 X50 0.3721 -0.2043 0.2312
X6 0.6882 -0.3893 0.0458
X7 0.4809 -0.3359 0.1328
X8 0.6016 -0.3721 X90 0.3721 -0.3636 0.1818
X10 0.7386 -0.1417 0.1850
X11 0.5118 0.2482 0.4672
X12 0.6861 -0.4497 X130 0.4497 -0.1932 0.2500
X14 0.6932 0.5429 0.7714
X15 1 -0.4397 X160 0.4397 0.3678 0.6437
X17 0.9195 -0.3144 X180 0.3144 -0.3721 X190 0.3721 -0.3879 X200 0.3879
AB 0.1837
-0.2857 0.5459
0.0765 0.9082
0.4388 -0.0392
-0.3765 0.2745
0 0.5882
0.3765 0.2268
-0.3711 0.5979
0 0.9691
0.3711 0.2358
-0.0849 0.5519
0.2358 0.8679
0.5566 -0.2054
-0.3721 0.1357
0 0.4767
0.3721 -0.4839
-0.2043 0.0323
0.2312 0.5699
0.6882 0.0382
-0.3893 0.3969
0.0458 0.7557
0.4809 0.2344
-0.3359 0.6172
0.1328 1
0.6016 -0.2054
-0.3721 0.1357
0 0.4767
0.3721 -0.2841
-0.3636 0.2443
0.1818 0.7841
0.7386 -0.1575
-0.1417 0.1811
0.1850 0.5197
0.5118 -0.1460
0.2482 0
0.4672 0.1460
0.6861 -0.2604
-0.4497 0.1420
0 0.5444
0.4497 -0.3182
-0.1932 0
0.2500 0.3182
0.6932 0.2229
0.5429 0.3400
0.7714 0.4571
1 -0.1348
-0.4397 0.2730
0 0.6809
0.4397 0.3736
0.3678 0.6868
0.6437 1
0.9195 -0.1907
-0.3144 0.0979
0 0.3866
0.3144 -0.2054
-0.3721 0.1357
0 0.4767
0.3721 -0.2543
-0.3879 0.1013
0 0.4569
0.3879
BC -0.0102
0.1837 0.3571
0.5459 0.7245
0.9082 -0.2824
-0.0392 0.0706
0.2745 0.4235
0.5882 -0.1134
0.2268 0.2680
0.5979 0.6495
0.9691 -0.0189
0.2358 0.3019
0.5519 0.6226
0.8679 0.0659
-0.2054 0.3624
0.1357 0.6589
0.4767 -0.4731
-0.4839 0.0054
0.0323 0.5054
0.5699 0.0763
0.0382 0.4313
0.3969 0.7863
0.7557 -0.5234
0.2344 0
0.6172 0.5234
1 -0.0388
-0.2054 0.2713
0.1357 0.5814
0.4767 0.0227
-0.2841 0.5057
0.2443 1
0.7841 0.1417
-0.1575 0.4449
0.1811 0.7480
0.5197 0.0365
-0.1460 0.2263
0 0.4161
0.1460 -0.1361
-0.2604 0.2278
0.1420 0.5917
0.5444 -0.1250
-0.3182 0.4375
0 1
0.3182 0.3086
0.2229 0.4571
0.3400 0.6057
0.4571 0.1773
-0.1348 0.5000
0.2730 0.8227
0.6809 -0.0345
0.3736 0.1552
0.6868 0.3448
1 -0.1392
-0.1907 0.1778
0.0979 0.4948
0.3866 -0.0388
-0.2054 0.2713
0.1357 0.5814
0.4767 -0.0172
-0.2543 0.3017
0.1013 0.6207
0.4569
CD 0.2245
-0.0102 0.5918
0.3571 0.9592
0.7245 -0.2078
-0.2824 0.1373
0.0706 0.4824
0.4235 0.2577
-0.1134 0.6289
0.2680 1
0.6495 0.3868
-0.0189 0.6934
0.3019 1
0.6226 0
0.0659 0
0.3624 0
0.6589 0.1398
-0.4731 0.5591
0.0054 1
0.5054 0.0763
0.0763 0.4466
0.4313 0.8168
0.7863 0.0469
-0.5234 0.4531
0 0.8594
0.5234 0.1279
-0.0388 0.4070
0.2713 0.6860
0.5814 -0.2045
0.0227 0.3239
0.5057 0.8636
1 -0.3701
0.1417 0
0.4449 0.3701
0.7480 0.0292
0.0365 0.2372
0.2263 0.4453
0.4161 0.1598
-0.1361 0.4822
0.2278 0.8047
0.5917 -0.1250
-0.1250 0.2159
0.4375 0.5568
1 0.5600
0.3086 0.7629
0.4571 0.9657
0.6057 -0.0638
0.1773 0.2908
0.5000 0.6454
0.8227 0.1149
-0.0345 0.3075
0.1552 0.5000
0.3448 0.0309
-0.1392 0.3119
0.1778 0.5928
0.4948 0.1279
-0.0388 0.4070
0.2713 0.6860
0.5814 0.1595
-0.0172 0.4418
0.3017 0.7241
0.6207
DE -0.2755
0.2245 0.0969
0.5918 0.4694
0.9592 0.4000
-0.2078 0.6294
0.1373 0.8588
0.4824 -0.3093
0.2577 0.0773
0.6289 0.4639
1 -0.2547
0.3868 0.0566
0.6934 0.3679
1 0.1279
0 0.4070
0 0.6860
0 -0.4516
0.1398 0.0323
0.5591 0.5376
1 0.2672
0.0763 0.6336
0.4466 1
0.8168 -0.0234
0.0469 0.3867
0.4531 0.7969
0.8594 0.2946
0.1279 0.5426
0.4070 0.7907
0.6860 -0.5795
-0.2045 0
0.3239 0.5909
0.8636 0.0945
-0.3701 0.4094
0 0.7244
0.3701 0
0.0292 0.1898
0.2372 0.3796
0.4453 0.3905
0.1598 0.6805
0.4822 0.9704
0.8047 -0.0682
-0.1250 0.3011
0.2159 0.6705
0.5568 0.1771
0.5600 0.3343
0.7629 0.4914
0.9657 0.4326
-0.0638 0.7163
0.2908 1
0.6454 -0.0920
0.1149 0.1207
0.3075 0.3333
0.5000 0.2526
0.0309 0.4923
0.3119 0.7320
0.5928 0.2946
0.1279 0.5426
0.4070 0.7907
0.6860 0.3276
0.1595 0.5819
0.4418 0.8362
0.7241
EF 0.2959
-0.2755 0.6480
0.0969 1
0.4694 0.5373
0.4000 0.7569
0.6294 0.9765
0.8588 0.0928
-0.3093 0.4691
0.0773 0.8454
0.4639 -0.0189
-0.2547 0.3019
0.0566 0.6226
0.3679 0.3333
0.1279 0.5775
0.4070 0.8217
0.6860 -0.1935
-0.4516 0.2688
0.0323 0.7527
0.5376 0.1527
0.2672 0.5076
0.6336 0.8626
1 -0.4688
-0.0234 0.0312
0.3867 0.5313
0.7969 0.4612
0.2946 0.6783
0.5426 0.8953
0.7907 -0.5909
-0.5795 0.0398
0 0.6818
0.5909 0.4961
0.0945 0.7480
0.4094 1
0.7244 0.0657
0 0.2883
0.1898 0.5109
0.3796 -0.0059
0.3905 0.3698
0.6805 0.7456
0.9704 -0.1818
-0.0682 0.2670
0.3011 0.7159
0.6705 0.2286
0.1771 0.3629
0.3343 0.4971
0.4914 0.0355
0.4326 0.4007
0.7163 0.7660
1 0.2069
-0.0920 0.4310
0.1207 0.6552
0.3333 0.4742
0.2526 0.6727
0.4923 0.8711
0.7320 0.4612
0.2946 0.6783
0.5426 0.8953
0.7907 0.4957
0.3276 0.7155
0.5819 0.9353
0.8362
FG -0.3571
0.2959 0
0.6480 0.3571
1 0.5961
0.5373 0.7980
0.7569 1
0.9765 -0.3196
0.0928 0.0619
0.4691 0.4433
0.8454 -0.2925
-0.0189 0
0.3019 0.2925
0.6226 0.5349
0.3333 0.7442
0.5775 0.9535
0.8217 -0.2903
-0.1935 0.1667
0.2688 0.6452
0.7527 -0.0076
0.1527 0.3664
0.5076 0.7405
0.8626 -0.0156
-0.4688 0.3984
0.0312 0.8125
0.5313 0
0.4612 0
0.6783 0
0.8953 -0.2500
-0.5909 0.2841
0.0398 0.8295
0.6818 0.1339
0.4961 0.4449
0.7480 0.7559
1 0.3796
0.0657 0.6898
0.2883 1
0.5109 0.4379
-0.0059 0.7189
0.3698 1
0.7456 0.0341
-0.1818 0.4943
0.2670 0.9545
0.7159 0.0800
0.2286 0.2286
0.3629 0.3771
0.4971 -0.2624
0.0355 0.1454
0.4007 0.5532
0.7660 -0.1149
0.2069 0.0489
0.4310 0.2126
0.6552 0.6701
0.4742 0.8351
0.6727 1
0.8711 0
0.4612 0
0.6783 0
0.8953 0.5819
0.4957 0.7909
0.7155 1
0.9353
GH 0.0612
-0.3571 0.4286
0 0.7959
0.3571 0.3098
0.5961 0.5706
0.7980 0.8314
1 -0.1134
-0.3196 0.2526
0.0619 0.6186
0.4433 -0.1981
-0.2925 0.1274
0 0.4528
0.2925 0.5620
0.5349 0.7578
0.7442 0.9535
0.9535 -0.5054
-0.2903 0
0.1667 0.5269
0.6452 -0.4427
-0.0076 0
0.3664 0.4427
0.7405 0.2109
-0.0156 0.5977
0.3984 0.9844
0.8125 0.5426
0 0.7403
0 0.9380
0 -0.1023
-0.2500 0.3977
0.2841 0.9091
0.8295 0.2992
0.1339 0.6181
0.4449 0.9370
0.7559 -0.0511
0.3796 0.2080
0.6898 0.4672
1 -0.1361
0.4379 0.2485
0.7189 0.6331
1 0.0568
0.0341 0.5284
0.4943 1
0.9545 -0.0800
0.0800 0
0.2286 0.0800
0.3771 0.1418
-0.2624 0.4787
0.1454 0.8156
0.5532 -0.1609
-0.1149 0
0.0489 0.1609
0.2126 0.6392
0.6701 0.8093
0.8351 0.9794
1 0.5930
0 0.7868
0 0.9806
0 0.5388
0.5819 0.7522
0.7909 0.9655
1
H 0.0612 0.4286 0.7959 0.3098 0.5706 0.8314 -0.1134 0.2526 0.6186 -0.1981 0.1274 0.4528 0.5620 0.7578 0.9535 -0.5054 0 0.5269 -0.4427 0 0.4427 0.2109 0.5977 0.9844 0.5426 0.7403 0.9380 -0.1023 0.3977 0.9091 0.2992 0.6181 0.9370 -0.0511 0.2080 0.4672 -0.1361 0.2485 0.6331 0.0568 0.5284 1 -0.0800 0 0.0800 0.1418 0.4787 0.8156 -0.1609 0 0.1609 0.6392 0.8093 0.9794 0.5930 0.7868 0.9806 0.5388 0.7522 0.9655
v 0.5
v 0.5
Alte rnative s Si Ri Qi Cris p Si Cris p Ri Cris p Qi
Alte rnative
A s -1.2141 Si
0.5283 2.4182 0.1243 Ri
0.1339 0.3966 -0.6047 Qi
0 0.6543 Cris p Si 1
0.5774 Cris p Ri 1
0.2183 Cris p Qi1
0.0165
B -0.5931 0.9961 2.7619 0.0661 0.2544 0.4211 -0.5905 0.1507 0.7103 1.0550 2 0.2472 2 0.0902 2
A -1.2141 0.5283 2.4182 0.1243 0.1339 0.3966 -0.6047 0 0.6543 0.5774 1 0.2183 1 0.0165 1
C
B -0.3467
-0.5931 1.2465
0.9961 3.0107
2.7619 0.0707
0.0661 0.2508
0.2544 0.5370
0.4211 -0.5614
-0.5905 0.1733
0.1507 0.8346
0.7103 1.3035
1.0550 3
2
0.2862
0.2472 2
3 0.1488
0.0902 3
2
D
C 0.2558
-0.3467 1.6942
1.2465 3.4000
3.0107 0.1282
0.0707 0.3237
0.2508 0.4638
0.5370 -0.4505
-0.5614 0.2814
0.1733 0.8122
0.8346 1.7833
1.3035 6
3 0.3053
0.2862 35 0.2143
0.1488 5
3
E 0.0179 1.4045 3.0359 0.1962 0.3614 0.5266 -0.4170 0.2837 0.8283 1.4861 5 0.3614 6 0.2317 6
D 0.2558 1.6942 3.4000 0.1282 0.3237 0.4638 -0.4505 0.2814 0.8122 1.7833 6 0.3053 5 0.2143 5
F 0.5896 2.1152 3.6588 0.3072 0.4517 0.5963 -0.2638 0.4336 0.9516 2.1212 8 0.4517 7 0.3738 7
E 0.0179 1.4045 3.0359 0.1962 0.3614 0.5266 -0.4170 0.2837 0.8283 1.4861 5 0.3614 6 0.2317 6
G 0.0897 1.2813 2.6366 0.1938 0.2634 0.4455 -0.4117 0.1876 0.7182 1.3359 4 0.3009 4 0.1647 4
F 0.5896 2.1152 3.6588 0.3072 0.4517 0.5963 -0.2638 0.4336 0.9516 2.1212 8 0.4517 7 0.3738 7
H 0.5014 1.8701 3.3289 0.3950 0.5240 0.6531 -0.1981 0.4700 0.9661 1.9001 7 0.5240 8 0.4127 8
G 0.0897 1.2813 2.6366 0.1938 0.2634 0.4455 -0.4117 0.1876 0.7182 1.3359 4 0.3009 4 0.1647 4
H 0.5014 1.8701 3.3289 0.3950 0.5240 0.6531 -0.1981 0.4700 0.9661 1.9001 7 0.5240 8 0.4127 8
Figure A4. Fuzzy Difference Dij. Source: Author’s own contribution.
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Ranking of Sustainable Medical Tourism Destinations in Iran: An Integrated Approach Using Fuzzy SWARA-PROMETHEE

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Ranking of Sustainable Medical Tourism Destinations in Iran: An Integrated Approach Using Fuzzy SWARA-PROMETHEE

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sustainability

1 Department of Industrial Engineering, South Tehran Branch, Islamic Azad University,

Keywords: medical tourism; fuzzy SWARA; PROMETHEE; sustainable development; consumer;

Sustainability 2021, 13, 683. https://doi.org/10.3390/su13020683 https://www.mdpi.com/journal/sustainability

tutions, lack of foreign marketing research, lack of overseas advertising system,

2.1. Medical Tourism

Table 1. Literature review.

2.2. Medical Tourism and Sustainability

2.3. Iranians and Medical Trips

2.4. Benefits and Reasons for Choosing Health Tourism as a Treatment

2.5. Analysis Methods

Figure 1. The 1.executive

3.1. Fuzzy SWARA

Table 2. Fuzzy and linguistic values [91].

Linguistic Scale Response Scale

d j ( a, b) = f j (a) − f j (b) j = 1, 2, . . . , k (4)

where w j represents the weight of the criterion j.

phi ( a) phi. (10)

4. Results and Discussion

Table 3. Identified sustainable criteria for choosing a medical tourism destination.

No Criteria Sustainability Dimension Sub-Criteria Definition

No Criteria Sustainability Dimension Sub-Criteria Definition

Table 4. The criteria and sub-criteria obtained by fuzzy SWARA.

Main Criteria Wj Sub-Criteria bj kj qj Wj Local Weight Global Weight

Table 5. Results of PROMETHEE calculation.

Actions Phi Phi+ Phi−

Table 6. Global decision matrix.

Table 7 shows the numerical values of the linguistic terms.

Table 7. Numerical values of the linguistic terms.

Linguistic Term Value

Table 8. Type of optimization of the sub-criteria and the preference functions.

Sustainability 2021, 13, x FOR PEER REVIEW 18 of 32

Table 9. PROMETHEE V global ranking.

Actions Net Flow Optimal

From the PROMETHEE 2 method, which is a complete ranking, we got a complete

Figure 5. PROMETHEE rainbow. Source: Author’s own contribution

Table 10. Verification of the results.

nability 2021, 13, x FOR PEER REVIEW 22 of 32

Figure 6 also shows

Initial Comparison Matrices

Left Criteria Is Greater Right Criteria Is Greater

FUZZY VIKOR: In this article,FUZZY VIKOR:

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