Medical Tourism Markets: Models of Sustainability. The Case of Spain and The Costa del Sol (Malaga)

Round 1

Reviewer 1 Report

The topic of the paper has potential interest in the medical tourism sector but the paper doesn’t clearly indicate the general aim and the objective of the study. Due to this, the overall presentation is confusing, without a clear and simple structure that explains how the objective is achieved and the results.

The title only partially reflects the content of the paper; the authors mainly give a very good background description of the medical tourism market in the province of Malaga, in economic numbers and in facilities. It seems that the province of Malaga has invested a lot in this sector to provide not only ex-pats with medical services, but also to attract their compatriots or other international tourists to the area of Costa del Sol – Malaga, for the same reasons and others.

However, the concept of sustainability is not accurately introduced in relation to this economic sector and it’s barely assessed. At the very beginning of the introduction, authors mention that the sustainability of the medical tourism is uneven (line 32) and then, at line 53, they write that “this paper begins by outlining the broad basis for the general sustainability of the medical tourism”, but it is not really clear what they have actually investigated except for background information and data. There is no clear assessment of the sustainability of the sector in the province of Malaga, and there are speculations in the discussions, in terms of challenges that the sector is facing and will face in the future, but also suggestions that originate from other works [ref. 56, 57].  

In my opinion, the paper slightly misses the scientific character; in addition, most numbers come from previous studies, so that the paper looks like a general communication or denounce against the local system. This is also reinforced by colorful statements (lines 415-421) that should be provided with specific proofs or citations.

I would suggest authors to define better the overall aim of the study, the objective (e.g. evaluating the suitability of medical tourism system in Malaga?), the method to reach it and the results.

It would be interesting to provide economic scenarios/estimations of the sector in function of geopolitical changes, as it seems that you have access to statistics on economic data.

What is important is to provide realistic and consistent considerations on the basis of an investigation.

More details about the text of the manuscript:

To me, chapters 4 and 5 might be merged. Many information and statistics reported do not show the relative reference or data source and some information seems to be connected to figure 1 and table 5.

Lines 89-93: add a reference.

Lines 93-95: add a reference.

Lines: 101-103 add a reference or weblink.

Line 113: in “(9.85)”, add “%” sign.

Line 116: delete double parenthesis in (15.4%))

Lines 120-128: Add references.

Lines 172-175: Add references or weblinks.

Lines 181-183: Add a reference. As you mention “quality of life”, give also more details about what “quality of life” is due to in such context.

Lines 188-189: Add a reference or a weblink.

Lines 316-326: Add references.

Lines 340-342: Add a reference.

Line 347: check the sentence

Line 412: “inadequate and obsolete infrastructure” is in contradiction with “ modern infrastructure” at line 141. Do you refer to the same town/context?

Line 415: Do you have a reference for the statement “The ego factor has been also mentioned as a key reason for failing [..]” until line 417 and then lines 419-421?

In case an acronym is rarely used, provide its long name (e.g. FCO, IPS)

Author Response

Reviewer 1:

1) We have included additional ideas and concepts of sustainability in relation to medical tourism sector.

2) In the introduction, we have defined better the overall aim of the study, objectives, method and the main results, as the reviewer suggested.

3) We have provided different economic scenarios/estimations of the sector in function of geopolitical changes.

4) All details about the text of the manuscript mentioned by the reviewer have been corrected. Many thanks.

• We have merged chapters 4 and 5. Following the reviewer 2’ recommendations, we had also changed the title of chapter 5 (now “Motivations for travel” instead of “Who travel? Why? For what?”).
• Lines 89-93: we have included the reference.
• Lines 93-95: we have included the reference.
• Lines 101-103: we have included the reference.
• Line 113: we have added “%” sign.
• Line 116: we have deleted double parenthesis in (15.4%)).
• Lines 120-128: we have included a reference and web link.
• Lines 172-175: we have included the reference.
• Lines 181-183: we have included the reference and have changed the expression “quality of life” for “welfare”.
• Lines 188-189: we have included the reference.
• Lines 316-326: we have included the reference.
• Lines 340-342: we have included the reference.
• Line 347: We have checked the sentence.
• Line 412: We refers to the results obtained by the Center for Health Tourism Strategy at an international level. In any case, we have modified the sentence to avoid any misunderstanding.
• Line 415: we have included the reference.
• As for acronyms, we have included its long name (e.g. FCO, IPS, OECD, GDP, etc.).

Reviewer 2 Report

I think this paper was reasonably interesting although it started off very slowly and I was thinking this is just another paper promoting medical tourism in Spain and specifically in the province of Malaga. 

In the first half of the paper there were lots of minor problems with your English writing and I became a little annoyed by your writing style. Lot of data presented, but I kept thinking - so what? How is this information important and how is it contributing to the field of tourism research?

Medical tourism is a very well researched topic and the authors did not really present any new information or research e.g., British ex-pats move to Malaga because they want to avoid the waiting lists for treatment by the NHS. I have been reading these types of findings for many years in previous medical tourism studies. Furthermore, other researchers can get this data as it is readily available.

Line 216 need a new heading - Motivations for travel.

The second half of the paper from around Line 450 was a big improvement in the paper. This was because the researchers began to critically analysing the information such as looking at the effects of corona virus and Brexit on the medical tourism industry in Spain. This was much more interesting and worthy of publication. I enjoyed reading it. 

Near the end of your paper I was looking for your conclusion and summary of your major findings but there was none. Nor was there any discussion of limitations to your study, or suggestions for further research. This was a major failing of your study.

Author Response

Reviewer 2:

1) We have reviewed the English language and style.

2) To improve the contribution of the paper, we have reduced the first part of the paper related to the existing data on Spain, Andalusia and Malaga.

3) We have changed the heading on page 5 (line 216) according to the reviewer’s suggestion. In addition and following the reviewer 1`s recommendation, we have merged chapter 4 and 5. As a result, the heading of the new chapter 4 is “Data on Andalusia and Malaga (The Costa del Sol): Motivations for travel”.

4) We thank your comments on the second half of the paper concerning the effects of coronavirus and Brexit.

5) We have included a conclusion sections with the major findings of the study, limitations, and future areas of research.

Reviewer 3 Report

I appreciate the opportunity to review the paper “Medical tourism markets: models of sustainability. The case of Spain and The Costa del Sol (Malaga)”. The research poses interesting research questions in terms of analyzing the sustainability of medical tourism model in Spain, and in The Costa del Sol.

In this review, I will present some suggestions that I think could help the authors improve their paper.

The title describes correctly the paper. The abstract states the main objectives of the paper and captures the attention to continue reading the research. It is also informative, describing the results and the major themes on the topic.

1. Introduction

The introduction starts by clearly presenting the importance of the topic under analysis and sets correctly the context.  So, I would say introduction is prepared fairly well, justifying the choice of research problem and the different problems faced by the major destination for medical travelers from the UK.

2. Theoretical framework

The theoretical framework is interesting but should be developed in depth.

References on this part are limited to three and are not updated (i.e. 2008, 2009, 2012). Only one of these is indexed on the WOS.

3. Methodology

In my opinion, authors have to justify and explain better their decision with the sample and justify why the authors have to choose these criteria and not others.

4. Discussion

In this section, authors confirm the importance of their paper by discussing the arguments by different perspectives, also including the coronavirus crisis which is taking place right now. The identification of threats and weakness is also relevant. But I would recommend linking the conclusions with previous research published in the topic.

The future research lines and limitations of the study should also be highlighted and developed further.

As minor issues, please review the paper by a professional proofreader to ensure the quality of the language on the manuscript.

IN SUM: Minor revision

Author Response

1) Introduction: Thanks for your comments.

2) To improve the theoretical framework of the paper, we have included more comments and updated references, as the reviewer recommended.

3) As noted on old page 5 (lines 217-219), one of the main limitations to investigate health/medical tourism is the lack of reliable and comparable international data. In our case, we have adopted an approach based on quantitative and qualitative data (from public and private sources) and similar to other existing studies on medical tourism (e.g. Ebrahik and Ganguli, 2017; Taheri, Chalmers, Wilson and Arshed, 2021). In particular, we have taken data from by the Spanish National Statistical Institute (quantitative data), and the Chair of “Tourism, Health and Wellbeing” of the University of Malaga (quantitative and qualitative data). These two sources were the only ones to include these kind of data at a local level. In any case and according to Cornell (2016), we have to bear in mind that the key point about the lack of appropriate data on the magnitude of medical tourism is that they are held in private hands and in organizations with important commercial interest in this sector. Horsfall and Lunt (2015) conclude that “estimating the global flows of medical tourists is not simply difficult, it only reveals part of the story (pp. 33)”. We have included these comments on page 5.

References:

• Ahmed Husain Ebrahim, Subhadra Ganguli (2017). Strategic priorities for exploiting Bahrain’s medical. Journal of Place Management and Development, 10(1), 45-60.
• Babak Taheri, Dominic Chalmers, Juliette Wilson, Norin Arshed (2021). Would you really recommend it? Antecedents of word-of-mouth in medical tourism. Tourism Management, 83, online first.
• Connell John (2016). Reducing the scale? From global images to border crossings in medical tourism. Global Networks 16, 4, 531-550.
• Horsfall, Daniel and Lunt, Neil (2015). Medical tourism by numbers. In Lunt, N., Horsfall, D. and Hanefeld, J. (eds.). Handbook on Medical tourism and Patient Mobility. 25-36.

4) Conclusions: We have linked conclusions with previous research. Future lines and limitations of the study have being included, as well a review of English language and style.

Round 2

Reviewer 1 Report

Authors have considered the suggestions and the paper has been improved.

Reviewer 2 Report

I am very pleased with the changes that have been made by the authors.

The introduction is much stronger with more up to date references that have been used to strengthen the paper, and has been nicely linked to the concept of sustainability.

The paper reads much better and has obviously been copy edited by a professional editor.

The section on the use of data for the region has been reduced as was previously suggested.

The conclusion has been included and it has really strengthened the paper to a high level. Further questions have been included to encourage future research.

I am very happy with the changes that the authors have made and recommend publication of this paper