Exploring Service Needs and Development Strategies for the Healthcare Tourism Industry Through the APA-NRM Technique

Abstract

With the arrival of an aging society and the continuous extension of the human lifespan, the quality of life has not improved in a corresponding manner. People’s demand for happiness and health is increasing. As a result, a model emerged that integrates tourism and medical services, which is health tourism. This growing demand has prompted many service providers to see it as a business opportunity and enter the market. Tourism can help travelers release work stress and restore physical and mental balance; meanwhile, health check-ups and disease treatment can help them regain health. Consumers have long favored health and medical tourism because it helps relieve stress and promotes overall well-being. As people age, some consumers experience a gradual decline in physical functions, making it difficult for them to participate in regular travel services provided by traditional travel agencies. Therefore, this study aims to explore the service needs of health and medical tourism customers (tourists/patients) and the interrelationships among these service needs, so that health and medical tourism service providers can develop more customized and diversified services. This study identifies four key drivers of medical tourism services: medical services, medical facilities, tour planning, and hospitality facilities. This study uses the APA (attention and performance analysis) method to assess each dimension and criterion and utilizes the DEMATEL method with the NRM (network relationship map) to identify network relationships. By combining APA and NRM techniques, this study develops the APA-NRM technique to evaluate adoption strategies and identify suitable paths for health tourism services, providing tailored development strategies and recommendations for service providers to enhance the service experience.

1. Introduction

With the development of medical technology and improvements in people’s quality of life, the average life expectancy has increased annually. For silver-haired people, longevity is no longer a challenge; a happy and healthy life is their ultimate goal. After World War II, the baby boom was an economic boom that increased wealth and quality of life. However, most of the post-war boom generation has had a whole family with children and grandchildren, achieved a successful career, and is now preparing for retirement. Medical advances have led to people living longer, but not all middle-aged and elderly people can live a healthy and happy life. Some cannot leave family ties and cannot travel abroad to enjoy a free life; others are concerned about their declining health and fear that their physical limitations may hinder their travel companions. These factors make many middle-aged and elderly people reluctant to travel. Therefore, the focus of new medical and health tourism is to help middle-aged and elderly people recover their health and discover the joys of life through travel.

To meet these needs, many travel operators have begun to design products and services specifically for middle-aged and elderly people. These travel products focus on selecting accessible tourist attractions, offering health management, and monitoring safety during the trip. For example, they provide professional medical advice, health checks, wellness courses, and other services that allow older people to enjoy leisure and health simultaneously during their travels. In addition, some travel trips specifically for silver-haired people will consider their physical abilities and interests and arrange suitable activities and schedules so that they can experience foreign cultures in a comfortable environment. Finally, as the population aging trend becomes increasingly clear, the medical and health tourism market targeting the silver-haired generation has tremendous potential. By providing personalized and professional services, we can help middle-aged and elderly people rediscover the joy of traveling and maintain their health during their visits, thus improving their quality of life and providing new opportunities for development in the tourism industry.

Due to their quality, cost, and ease of access to treatment, wealthy tourists will choose surgeries in developing destinations. A study on medical tourism in the Sunshine Coast of Australia concluded that medical tourism was outbound tourism. This study explored the potential of regional medical tourism. The researcher noted that the three existing challenges included the friendly attitude of doctors, the use of hospital facilities by residents, and the need for more cooperation in the Sunshine Coast, Australia. This study examined regional medical tourism’s competitive relationship with various stakeholders and the development strategies of medical tourism [1]. Health tourism has garnered increasing interest from both academia and industry. A prior study investigated health tourism with a particular emphasis on developing countries, analyzing how major tourist source markets—such as the United States—affect tourism demand, as well as the influence of health tourism expenditures in developed nations like Canada. Using a time series analysis covering the period from 1986 to 2016, this study evaluated the roles of price and volume in shaping health tourism trends. The findings revealed that demand for tourism in the United States has a sustained, positive impact on Canada’s total medical tourism spending. Furthermore, the research offered essential recommendations for advancing health tourism in Canada [2]. Recently, the industrial development of medical tourism has increased as governments seek new sectors for sustainable growth. Increased cooperation in medical tourism and the health and medical sectors can improve relations between countries. The growth rate of international tourism is higher than ever because of globalization. The growth of global tourism contributes to the development of the economy, politics, cultural relations, and social cooperation. The rapid industrial development of medical tourism could enhance cooperation in the medical and health sectors, especially in the United Arab Emirates and South Korea. This study indicates that expanding medical tourism will strengthen cultural exchanges and establish new cooperation relations in the health and medical fields [3].

Medical tourism plays a crucial role in the tourism industry and has a profound impact on the economies of host countries. Nations compete to attract medical tourists, though their motivations differ across cultures. As international medical tourism continues to grow, healthcare leaders must develop effective marketing strategies to maintain their market share. Iranian research revealed that, despite political issues, the country’s advanced medical services and attractions are appealing to international patients. Future studies should focus on identifying key success factors for medical tourism in each nation using decision-making tools [4]. Health tourism is a complex and diverse field, yet it is also an industry experiencing rapid growth and significant economic opportunities. This sector represents a convergence of two key areas: healthcare and tourism, facilitating an exchange of services. Researchers have explored the advantages and challenges faced by medical tourism providers in central Macedonia, as well as investigated the factors that influence sustainability within Greece’s medical tourism industry. The primary objective of these studies is to propose effective strategies that strike a balance between the economic benefits of medical tourism and its environmental and social responsibilities [5]. A study explored the critical factors influencing the selection of medical tourism destinations. This study found that referring patients by word of mouth (WOM) was the most crucial link channel in the medical tourism industry, and about 55% of patients were referred by patients who had previously been treated. Patients received information on medical services primarily through lifelong interactions, including recommendations from former patients, families, or friends, contacts through other services, referrals from medical professionals, and through the visibility of services in the neighborhood. The research results indicated that patients referred through the WOM usually have higher satisfaction levels and are more likely to become repeat customers, thus increasing the income and reputation of healthcare institutions. Furthermore, because of the common language and historical background between Chinese tourists and Taiwanese, direct communication with doctors on personal matters is more effective than relying on translators [6]. This study identified four aspects (medical services, medical facilities, tour planning, and hospitality facilities) to assess travelers’/patients’ preferences. The researchers employed the APA technique (attention and performance analysis) to assess attention and performance status, service preferences, and service gaps. The NRM (network relation map) technique is a network structure technique used to evaluate medical tourism systems. Additionally, this study integrates the APA (attention and performance analysis) and NRM (network relation map) techniques and proposes the APA-NRM technique. This proposed method can help medical tourism providers evaluate suitable adoption strategies and paths to improve service quality and attractiveness for the medical tourism industry.

The present study consists of five sections. Section 2 explores the driving forces behind the healthcare tourism evaluation system. Section 3 introduces the APA-NRM technique (attention and performance analysis–network relation map) and proposes suitable adoption paths. Section 4 describes case-based studies on healthcare tourism to explain the adoption strategies and suitable paths based on the APA-NRM technique. Finally, Section 5 provides future research directions and some valuable recommendations.

2. Literature Review

2.1. The Critical Driving Factors for the Evaluation System of Healthcare Tourism

Geriatric tourism is a new style involving health, medical, and wellness tourism. This study examined the innovative approach of senior tourism packages and the service needs of geriatric tourism hospitality and tourism in a holistic approach. Geriatric tourism consumers are people who are, but not necessarily, long-term care recipients for frailty, multiple diseases, and possibly a slight cognitive impairment. Geriatric tourism can be adopted for entertainment, not treatment and care. Researchers believe travelers over 50 cannot represent the segment of the market for senior tourism because these tourism products can attract clients of different ages. A study found that senior tourism differed from medical or health tourism. During travel, geriatric tourism can provide long-term treatment and care services for elderly travelers and meet the leisure needs of elderly travelers [7]. With the globalization of medical services, Asia has become a top destination for international patients seeking high-quality, affordable care. Monitoring the quality of the global medical industry is essential to maintain demand. There has been little discussion of healthcare professionals’ experiences in providing international medical services (IMSs) to cancer patients. One study interviewed 19 Taiwanese cancer doctors and identified four main themes: patient selection, psychological support, service conditions, and promotional recommendations, highlighting the importance of improving IMS quality for hospital development. It is recommended that healthcare professionals, administrators, and policymakers collaborate to enhance the quality of IMSs for international cancer care [8]. In addition, wellness activities include traditional healing practices, thermal treatments, gentle exercise programs, and nutrition consultations. These comprehensive services enable people to regain the joy of traveling while maintaining their health. Medical care is integrated into tourism to ensure safety and comfort and provide a meaningful and enriching travel experience. The global trend toward aging the world’s population, particularly in developed countries, has created significant opportunities for medical and health tourism markets targeting the silver-haired generation. This demographic change has enabled the health and tourism sectors to cooperate and develop specialized services to meet the specific needs of elderly travelers. The industry provides personalized professional services for a wide range of elderly care and travel. These include personalized medical programs with regular health monitoring, specialized consultations, preventive healthcare, and rehabilitation services. Improved travel experiences can be provided by accessible transportation, age-friendly accommodations, adapted tour routes, and emergency medical support, as shown in

Table 1. The descriptions of aspects/criteria for healthcare tourism evaluation systems.

Aspects/Criteria	Descriptions
Medical services (MSs)
Reservation service (MS1)	The doctor and nurse will assist patients with confirming surgical procedures, appointments, personal payment, insurance applications, and other appointment scheduling services.
Treatment assessment (MS2)	Doctors, nurses, and medical technicians will assist patients in arranging physical examinations and diagnostic tests, provide medical advice, and obtain informed consent at the end of the process.
Medical surgery (MS3)	Doctors and nurses will confirm the patient’s condition and assist in arranging cross-disciplinary surgery, anesthesia processes, specialized surgeries, and coordinating support services.
Postoperative recovery (MS4)	After the patient has completed the surgery, the nurse will assist the patient in arranging cross-disciplinary medical treatment, specialized medical treatment, postoperative outpatient, and home medical services.
Medical facilities (MFs)
Surgical equipment (MF1)	The facility will provide a safe and comfortable sterile surgical environment for patients to avoid infections during surgery and thereby increase the chances of patient recovery.
Diagnosis facility (MF2)	The facility will provide customized medical and nursing services that respect patient privacy, allowing postoperative patients to recover and return home with adequate medical care.
Medical equipment (MF3)	The facility will provide emergency medical rescue facilities and related advanced medical and surgical equipment to reduce the burden on the patient’s body and improve the recovery rate.
Medical examination facilities (MF4)	The facility will provide travelers/patients with a complete full-body health check-up and arrange for relevant blood tests and organ function examinations before the patient’s surgery.
Tour planning (TP)
Intercity sightseeing (TP1)	Tour guides and leaders will assist clients, their friends, and their families in arranging long-distance travel that spans more than a day, crosses two counties, and includes accommodation and tours.
City tour (TP2)	Tour guides and leaders will help clients and their friends and family arrange city sightseeing, attraction visits, and short-term travel services that do not require accommodation.
Reception service (TP3)	Tour guides and leaders will assist clients and their friends and family in arranging airport pick-up services, accommodation arrangements, and guidance on subsequent itinerary arrangements and introductions.
Traffic connection (TP4)	Travel agency bus drivers and outsourced shuttle service personnel assist clients, friends, and family with shuttle services between accommodation and tour attractions.
Hospitality facilities (HFs)
Accommodation facilities (HF1)	During the journey, patients/travelers are provided with a home-like environment to relieve fatigue and get sufficient rest.
Restaurant facilities (HF2)	During the journey, patients/travelers can taste local cuisine, replenishing their energy and allowing them to enjoy regional delicacies.
Emergency treatment (HF3)	During the journey, adequate medical emergency measures are provided for patients/travelers, therefore reducing their worries.
Medical connection (HF4)	During the journey, an emergency medical network is established with the local medical system at all times to provide emergency medical shuttle services when necessary.

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2.1.1. Medical Services (MSs)

With the increasing global convenience of medical tourism, more patients are traveling abroad for treatment, drawn by the quality of services and facilities. However, issues such as unequal service distribution and patient complaints persist. Using fairness theory, a study surveyed 354 cosmetic medical tourists in Korea and analyzed online feedback. Results show that outcome fairness has the most significant impact on dissatisfaction, followed by interpersonal, procedural, and informational fairness. Dissatisfied patients are more likely to complain, spread negative word of mouth, or switch providers, with the level of participation affecting these behaviors. Therefore, this study suggests that providing fair medical services and implementing effective complaint and service recovery strategies are crucial for reducing dissatisfaction among medical tourists [9]. Medical tourism combines health and wellness tourism and is becoming increasingly popular worldwide. Researchers examined the key factors influencing Malaysia’s medical tourism development. The researchers established a framework for evaluations through literature reviews. They adopted the DEMATEL (decision-comparative evaluation laboratory) and the fuzzy TOPSIS (fuzzy preference order by similarity to ideal solution) to assess the structure of Malaysia’s medical tourism relationship and the performance of the evaluation service. The research indicated that technological and human factors are the most critical factors for adopting medical tourism in Malaysia. This study proposed valuable suggestions for medical tourism service providers in developing countries [10]. Another study examined the role and significance of perceived risks in medical tourism (MT). Researchers showed that the origin country and self-assessment of the health status of respondents significantly reduced their attitude toward behavioral intentions. The perception of the risk of MT services is strongly related to their attitudes, and the awareness, sensitivity, and kind of risk significantly moderate this relationship. Furthermore, the model’s key factor is satisfaction with the country’s medical services. In Jordan, Poland, and Turkey, a comprehensive, structured questionnaire was conducted for young consumers, and several regression models were used to verify the hypothesis [11]. Medical tourism is a growing industry of billions of dollars. Low costs, all-inclusive vacation surgery packages, globalization, and affordable flights encourage patients to seek cosmetic surgery abroad. In a 12-year medical record survey, 56 patients were admitted to plastic surgery on average at age 37.46, of whom 91.07 percent were women. The most common procedures are liposuction (40 cases) and abdominoplasty (38 cases). Most patients are on multiple operations per trip (average of 2.34 procedures). The most common complication was surgical site dehiscence, with 11 patients requiring re-operation. Although medical tourism benefits both patients and health providers, short-term multiple procedures, short follow-ups, and different microbial environments have caused serious complications and have seriously affected many patients [12].

The patient care process is divided into several key stages. In the reservation service stage, doctors and nurses assist patients in confirming surgical procedures, scheduling appointments, handling personal payments, processing insurance applications, and managing other related scheduling needs. During treatment assessment, a team of doctors, nurses, and medical technicians helps patients arrange physical examinations and diagnostic tests, provides medical advice, and ensures informed consent. Before surgery, doctors and nurses evaluate the patient’s condition and coordinate all aspects of the procedure, including cross-disciplinary surgeries, anesthesia, specialized operations, and necessary support services. After surgery, nurses support patients throughout their recovery by arranging further specialized or cross-disciplinary treatments, managing postoperative outpatient visits, and facilitating home medical services to ensure comprehensive ongoing care. Therefore, how to enhance medical and care services in health tourism has become a central focus for researchers in this field. Medical and care services are a critical factor in the attractiveness of health tourism destinations and an essential element in maintaining customer satisfaction, as presented in Table 1.

2.1.2. Medical Facilities (MFs)

Hospital websites can promote staff expertise, medical facilities, medical treatments and services, and medical equipment for foreign and domestic patients. A study explored the websites of these private hospitals in three competitive Asian countries (India, Thailand, and Malaysia). The authors analyzed how these hospitals present themselves and understand the needs of future medical tourists. The researchers examined the form and content of 51 hospitals’ websites using five aspects (technology, interactive online services, hospital facilities and information, medical services and admissions, and external activities). The findings noted that the websites of Thai, Indian, and Malaysian hospitals have differences, and hospital managers need to strengthen the interaction between hospital websites and the online presence of hospitals [13]. Medical tourism research focuses on the driving factors of destination images based on data from private hospitals in Malaysia. The research results indicated that the doctors’ expertise, hospitals’ facilities, perceived warmth, and perceived competence can influence the image of a medical tourism destination, and interaction with other patients plays a moderating role in certain relationships. This study offers valuable suggestions for destination images and may give practical ideas for medical tourism [14]. Mineral spa treatments and thermal treatments are critical therapeutic tools used in numerous scientific studies. This study adopts content analysis to determine the five essential factors of influence (location, room, thermal/spa, pool, and staff) through 1254 online reviews from 2015 to 2019. Researchers explore satisfaction and dissatisfaction with tourism attributes through sentiment analysis for thermal and mineral spa centers. Additionally, this study also provides valuable suggestions for tourism satisfaction and dissatisfaction with mineral spa centers [15].

Research conducted in Delhi, India, examined international cancer patients’ challenges when seeking medical care. Researchers surveyed 937 patients from 55 countries who sought treatment in Delhi between November 2013 and April 2019. This study found that patients primarily sought treatment abroad because of unreliable or unavailable medical services in their home countries. The average costs of treatment, travel, and accommodation were significant, causing financial difficulties for most patients and reducing their lifetime savings by 35%. This study concluded that patients traveling to Delhi for cancer treatment often exhausted their finances due to high costs, resulting in financial difficulties [16]. Medical tourism is one of the fastest-growing emerging industries in the world. The researchers studied social welfare control strategies for public hospitals developing medical tourism based on the theories of waiting and the theory of games. This study analyzed short- and long-term scenarios and examined whether public hospitals invest revenues from foreign patients to expand their capacity. The results showed that social planners should allow public hospitals to participate in medical tourism projects when public budgets and the profitability or attractiveness of tourism industries are sufficiently high (or when patient delays are adequately low). However, under certain conditions, the participation of public hospitals in medical tourism may affect patients’ well-being and increase government spending on the public hospital system [17]. More and more Americans travel abroad for bariatric surgery, with cases of postoperative complications often appearing in local emergency departments. A study reported three patients who experienced severe postoperative complications in Mexico after bariatric surgery and sought emergency care in rural community hospitals limited in resources in southern California near the U.S.–Mexico border. Such cases are expected to increase, especially in emergency departments near entry points, so emergency physicians need to know the associated clinical and operational challenges [18].

The surgical equipment is designed to create a safe, comfortable, and sterile environment, effectively preventing infections during surgery and increasing patient recovery rates. The diagnosis facility offers personalized medical and nursing care that respects patient privacy, helping postoperative patients recover and return home with appropriate support. Advanced medical equipment ensures the availability of emergency rescue and state-of-the-art surgical technology, reducing the physical burden on patients and enhancing their chances of recovery. Additionally, medical examination facilities offer comprehensive full-body check-ups, including blood tests and assessments of organ function, for travelers and patients before surgery, ensuring they receive optimal treatment. Medical facilities play an essential role in enhancing the appeal of health tourism destinations and are vital for ensuring customer satisfaction, as shown in Table 1.

2.1.3. Tour Planning (TP)

The distinction between medical treatment and medical tourism focuses on tourist activities and voluntary leisure; researchers explored this through interviews with travelers/patients who returned from medical treatments overseas. This study determined four criteria of influence factors: personal factors (travel companions, travel experience, and resilience), destination factors, travel experience, and financial issues. In addition, the level of invasiveness of medical procedures, the recovery requirements after treatment, and the relative complications of treatment play a crucial role for patients traveling. This study also points out that hospital “hotel isolation” has become more common, combining business and medical tourism to develop new hybrid tourism and leisure elements [19]. Health tourism has attracted the interest of medical professionals and researchers, but the understanding of health tourism still needs to be improved in today’s environment. A study proposed a logistic regression model of stereotypes for analyzing Italian health tourism using secondary data. The researchers believed that health tourism combines health and tourism to meet the different needs of tourists. The research results also indicated that Italian health tourism is still in its early stages, and health tourism prefers short-term trips and city tours. The authorities and related development must establish tailored policies and management interventions for Italy’s health tourism [20]. As an international tourist destination, all travelers’ needs must be met, particularly those with disability. However, the number of tourist agencies accommodating disabled tourists is unacceptable, with only seven in Korea. With the global population of older adults on the rise, likely, the number of people using wheelchairs will also increase. Busan is also facing the current problem of an aging population, as the elderly account for the country’s highest population. This study is the first to investigate the needs and preferences of Koreans with mobility impairments in the marine tourism sector. According to the survey, 110 beach wheelchair users reported being satisfied with their travel experience and expressed a willingness to participate again. These results underscore the need to develop tourism policies and environments that cater to travelers with mobility disabilities. Additionally, the tourism budget should be allocated to better meet the needs of travelers with mobility impairments and enhance the city’s standards as an international tourism destination [21].

Medical tourism is a new concept in health logistics in which patients travel to receive medical services of higher quality and at a lower price. This service is essential to developing countries. We have developed a practical optimization model that medical tour centers (MTCs) use to entrust patients to hospitals appropriately and create an unforgettable recovery experience. The main objective of this model is to maximize the total profits of MTCs by efficiently directing patients to hospitals while accounting for their recovery tours. The results highlighted the importance of tourist opinion and public preferences in medical and leisure travel and contribute to the economic growth of developing countries in this sector [22]. Enhancing the attractiveness of medical tourism destinations has increasingly drawn service providers’ attention. A recent study employed the fuzzy analytic hierarchy process (FAHP) to evaluate medical tourism destinations in emerging countries. Using this mixed-method approach, Indian medical tour operators analyzed patient decision-making patterns. The research identified India as a preferred destination because of cost-effectiveness and skilled medical staff, while Singapore and Thailand were noted for quality care and technology. The findings emphasized that treatment costs and healthcare quality primarily influenced patients’ choices and suggested governments should develop clear guidelines for marketing strategies. This study’s FAHP methodology provided unique insights for stakeholders in medical tourism [23]. More and more Chinese tourists are visiting Hong Kong for medical tourism. A study investigated the factors influencing medical tourism decisions for two groups from mainland China to Hong Kong. It also examined the correlation between these factors and the group’s personal visit and recommendation intention. Travelers generally considered personal gains, satisfaction with individual needs, and high medical acceptance capacities and quality. Local medical service constraints, perceived medical experience quality, and destination attributes determined the patients’ reactions to personal visits. Hong Kong’s medical tourism development offers unique cultural features, a base for the reputation of mass tourism, and a reputation for high-quality medical services promoted by third parties and various commercial channels [24].

Healthcare tourism services include comprehensive travel arrangements for clients and their companions. For intercity sightseeing, tour guides and leaders assist in planning multi-day journeys that cross country borders and include both accommodation and guided tours. For city tours, they help organize local sightseeing, visits to attractions, and short trips that do not require overnight stays. In addition, reception services ensure smooth airport pick-ups and accommodation arrangements, and guide upcoming itinerary details. Additionally, travel agency bus drivers and outsourced shuttle personnel handle transportation between accommodations and attractions, ensuring convenient and seamless transfers throughout the trip. A well-designed travel itinerary enables travelers to enjoy medical treatment and care more comfortably and reassuringly, while also allowing them to appreciate local scenery and experience the unique culture and lifestyle of the destination, as shown in Table 1.

2.1.4. Hospitality Facilities (HFs)

The number of travelers/patients, enterprises, and countries joining medical tourism continues to increase, but the understanding of the medical tourism destinations’ attractiveness is still lacking. Therefore, researchers established a medical tourism indicator to assess the performance of tourism destinations’ attractiveness. Researchers used four aspects (countries, hospital facilities and services, medical costs, and tourism) and thirty-four criteria to determine the medical tourism indicator (MTI) based on 4995 respondents. The research results found that the MTI can assess the differences in each aspect/criterion of a country and provide a variety of stakeholders with information to evaluate and manage their medical tourism destinations [25]. Research into factors that shape medical tourism destination choices has gained significant academic interest. A comprehensive study investigated how American patients select overseas healthcare destinations by examining 541 medical tourism cases through the Amazon Mechanical Turk platform. The research uncovered four primary determinants driving destination selection: the quality of healthcare facilities and services, characteristics of the host country, cost considerations, and the overall appeal of the destination. The findings highlighted that the most sought-after destinations among American medical tourists—Mexico, Turkey, India, China, and Thailand—achieved their popularity through advanced medical infrastructure and well-developed tourism facilities [26]. With their competitive advantages of medical expertise, safety, innovative technology, attractive tourist destinations, and medical tourism costs, the researchers collected six medical tourist destinations in the Asia-Pacific (Thailand, South Korea, Taiwan, Singapore, Malaysia, and India). The researchers adopt the grey system theory to establish the medical tourism industry’s performance evaluation system, considering economic impact factors. The research results indicated that healthcare, medical infrastructure, and tourist resources are vital in promoting the medical tourism industry. However, marketing efficiency and cost advantage have mainly been ignored. In addition, Thailand has been ranked as the best medical tourism destination after Malaysia, India, Singapore, South Korea, and Taiwan [27]. Medical tourism is considered one of the most profitable service industries in the world. Another study explored medical tourism in Thessaloniki, Greece, and investigated healthcare providers’ perspectives on industry potential and challenges. Research through a cross-sectional survey revealed private medical facilities’ higher participation in medical tourism, offering services such as dialysis, cancer treatment, orthopedics, and gynecology. Key success factors include quality healthcare, competitive pricing, cultural attractions, and a favorable climate. A study suggested medical tourism could significantly boost economic growth with proper policies, including facility investments, banking cooperation, and tax incentives [28]. Dental tourism has experienced rapid growth, driven by increasing customer demand and market value. This study proposes a MODM model to optimize sustainable development in dental tourism, encompassing the optimal layout and capacity for clinics and accommodations, transportation, and waste management. Factoring in biological risks, jobs, environment, and costs, the model offers governments and businesses actionable insights to establish sustainable and prosperous operations through validated case studies [29].

Accommodation facilities create a home-like atmosphere for patients and travelers, helping them relieve fatigue and receive quality rest throughout their journey. Restaurant facilities offer chances to savor local cuisine, allowing guests to restore their energy while enjoying regional specialties. Emergency treatment services ensure timely and appropriate medical care, alleviating concerns during travel. Meanwhile, a medical connection establishes a network with local healthcare providers, making it possible to arrange emergency medical transport whenever needed during the trip. High-quality hospitality facilities provide guests or patients with a warm and comfortable accommodation experience, allowing them to enjoy local specialties fully. In addition, in an emergency, these facilities can cooperate with nearby medical institutions to assist travelers or patients in obtaining timely medical referrals and transfer services, as shown in Table 1.

3. The Service System for Healthcare Tourism Using the APA-NRM Technique

This study adopted the APA-NRM (attention and performance analysis–network relation map) technique to analyze healthcare tourism assessment systems. The APA-NRM technique consists of six analysis processes: (1) definition of critical decision problems, (2) determination of aspects/criteria for assessment, (3) measurement of aspects/criteria for evaluation (APA technique), (4) determination of NRM (network relationship map), (5) determination of service adoption strategies (APA-NRM technique), and (6) determination of appropriate adoption paths, as presented in Figure 1.

3.1. The Population Sample Information, Explanation, and Reliability Analysis

This study targeted medical tourism participants and conducted a questionnaire survey. Four evaluation categories (medical services, medical facilities, tour planning, and hospitality facilities) and sixteen evaluation criteria can be defined by expert interviews and a literature review. This study employed both online and paper questionnaires to analyze the concerns and performance levels of different types of travelers (those traveling alone, with family or friends, or with company colleagues) regarding medical tourism. The survey was open from March 2024 to October 2024. A pilot test with 40 small sample questionnaires was conducted in advance to confirm that the reliability and validity met the expected requirements (Cronbach’s Alpha > 0.7) before proceeding to the formal research testing. A total of 160 completed questionnaires were collected, with 124 valid responses, as shown in

Table 2. The population information profile of valid samples.

		Frequency	Percentage (%)
Gender	Male	45	36.29%
	Female	79	63.71%
Age	Less than 39 years	32	25.81%
	40 to 49 years	47	37.90%
	50 to 59 years	32	25.81%
	Over 60 years	13	10.48%
Main travel companions	Traveling alone	17	13.71%
	Traveling with family/friends	94	75.81%
	Traveling with company colleagues	13	10.48%
	Total	124	100%

. The survey collected participants’ personal information, including gender, age, average annual income (NTD), medical tourism budget (NTD), and primary travel companion. The sample comprised 45 males and 79 females. Among them, 32 were under the age of 39, 47 were aged 40 to 49, 32 were aged 50 to 59, and 13 were aged 60 or above. Regarding primary travel companions, 17 were traveling alone, 94 were traveling with family or friends, and 13 were traveling with corporate colleagues, as shown in Table 2.

Cronbach’s Alpha (Cronbach $\alpha$) can adopted to analyze the degree of reliability of attention and performance for each aspect/criterion. The attention indicator’s Cronbach’s Alpha was 0.982, and the performance indicator’s Alpha was 0.986, which was also higher than the proposed 0.7 (Cronbach $\alpha$ > 0.7). Thus, the reliability indicators of attention and performance were highly consistent. Further, Cronbach’s Alpha of the evaluation aspect was 0.977, higher than the suggested 0.7 (Cronbach $\alpha$ > 0.7). So, the aspect’s reliability of the service system was highly consistent. The MSs (medical services) aspect Cronbach’s Alpha was 0.974, and the Cronbach’s Alpha of the MFs (medical facilities) aspect was 0.984. The TP (tour planning) aspect’s Cronbach’s Alpha was 0.967, and the Alpha of the HFs (hospitality facilities) aspect was 0.972. Hence, the reliability of the four aspects (MSs, MFs, TP, and HFs) was highly consistent, as presented in

Table 3. The reliability analysis (Cronbach $\alpha$).

Items	Aspects/Criteria	Alpha	Result
Attention indicator		0.982	High
Performance indicator		0.986	High
Aspects of evaluation system		0.977	High
Criteria of aspects	Medical services (MSs)	0.974	High
	Medical facilities (MFs)	0.984	High
	Tour planning (TP)	0.967	High
	Hospitality facilities (HFs)	0.972	High

Note: Cronbach suggests Alpha α-value: $\alpha \le 0.35$ is low reliability, $0.35<\alpha <0.70$ is middle reliability, $\alpha \ge 0.70$ is high reliability.

.

3.2. The APA (Attention and Performance Analysis) Analysis

The MFs (medical facilities) aspect is in the first quadrant (H, H). Therefore, travelers and patients believe the MFs aspect is crucial and high-performing for the healthcare tourism evaluation system. They pay attention to it and are satisfied with it. Consequently, adoption strategy A (continuous strengthening) could be used in the first quadrant. The TP (tour planning) aspect is in the second quadrant (L, H). Travelers/patients believe that TP (tour planning) aspects have received less attention, but they are satisfied with the evaluation system of healthcare tourism. However, travelers/patients pay little attention to TP aspects but are confident with the current ones. Thus, the status keeping strategy (adoption strategy B) could be used in the second quadrant. The MSs (medical services) and HFs (hospitality facilities) are located in the third quadrant (L, L). Consequently, travelers believe that the MSs and HFs aspects of the healthcare tourism evaluation system have received little attention and performance. Travelers ignore the MSs and HFs aspects, and they do not satisfy the MSs and HFs aspects. Travelers/patients can apply progressive development (adoption strategy C) to the third quadrant. Based on the APA analysis, healthcare tourism service providers should focus on these aspects in the third (L, L) quadrant, such as MSs and HFs aspects, as presented in

Table 4. The APA analysis for healthcare tourism.

	AI		PI		(AD, PD)
	MS	SS	MI	SI
Medical services (MSs)	6.597	−0.439	6.881	−0.018	L, L
Medical facilities (MFs)	7.127	1.461	7.111	1.160	H, H
Tour planning (TP)	6.653	−0.237	6.911	0.137	L, H
Hospitality facilities (HFs)	6.500	−0.786	6.635	−1.279	L, L
Average	7.127	1.461	7.111	1.160
Standard deviation	6.500	−0.786	6.635	−1.279
Maximum	6.719	0.000	6.885	0.000
Minimum	0.279	1.000	0.195	1.000

Note 1: (H, H) means the aspect/criterion is of high attention and high performance, and (H, L) means the aspect/criterion is of high attention and low performance. (L, L) means the aspect/criterion is of low attention and performance, and (L, H) means the aspect/criterion is of low attention but high performance. Note 2: MA, SS, MI, and SI mean attention, standardized attention, performance, and standardized performance, respectively.

and Figure 2.

3.3. The NRM Analysis Based on the DEMATEL Technique

The DEMATEL (decision-making trial and evaluation laboratory) technique is a valuable tool for decision-makers in analyzing complex problems through the network relation map (NRM) method. This approach has been successfully applied across various research fields. Recent applications include user interface analysis [30], failure sorting system evaluation [31], strategies development of science and technology park evaluation systems [32], optimization of threshold values [33], strategy development for vehicle telematics services [34], strategic supply chain management for recycled materials vendor selection [35], methodological improvements through modified DEMATEL [36], vehicle navigation systems product positioning [37], pharmaceutical company performance evaluation using fuzzy MCDM [38], digital music service assessment [39], analysis of critical factors in EMI (English-medium instruction) for MICE industry training [40], corporate sustainability in electronics [41], package tour service positioning [42], industrial heritage tourism enhancement [43], sustainable tourism strategies for urban and rural areas [44], talent development strategies in the service industry [45], regional development assessment in Colombia using SDG criteria [46], biomass energy challenges in Tehran [47], professional development in the coffee service industry [48], and green supplier selection using an integrated DEMATEL-ISM approach [49].

This study explains the DEMATEL approach into five stages: (1) analyze the original average matrix, (2) evaluate the direct influence matrix, (3) evaluate the indirect influence matrix, (4) determine the full influence matrix, and (5) determine the NRM (network relation map).

(1)

Analyze the original average matrix

The respondents evaluated the influence each aspect has on others by scales ranging from 0 to 4. “0” means “no influence,” and “4” indicates “extremely strong influence on others,” between the aspect/criterion; “1”, “2” and “3” indicate “low influence on others”, “medium influence on others” and “high influence on others”, respectively. The impact that “medical services (MS)” has on “medical facilities (MF)” is 3.202, which means “high influence,” as presented in

Table 5. The original average influence matrix (A).

Aspects	MS	MF	TP	HF	Total
Medical services (MSs)	0.000	3.202	2.847	2.847	8.895
Medical facilities (MFs)	3.226	0.000	2.847	2.823	8.895
Tour planning (TP)	2.919	2.992	0.000	3.073	8.984
Hospitality facilities (HFs)	2.871	2.871	3.040	0.000	8.782
Total	9.016	9.065	8.734	8.742	-

. The influence that “tour planning (TP)” has on “medical services (MS)” is 2.919, which also means “medium influence,” as shown in Table 5.

(2)

Evaluate the direct influence matrix

This study processed the original average influence matrix (A) using Equations (1) and (2) to obtain the “direct influence matrix” (D), as shown in

Table 6. The direct influence matrix (D).

Aspects	MS	MF	TP	HF	Total
Medical services (MSs)	0.000	0.353	0.314	0.314	0.981
Medical facilities (MFs)	0.356	0.000	0.314	0.311	0.981
Tour planning (TP)	0.322	0.330	0.000	0.339	0.991
Hospitality facilities (HFs)	0.317	0.317	0.335	0.000	0.969
Total	0.995	1.000	0.964	0.964	-

. The direct influence matrix (D) diagonal items are all zero, and the sum of a row/column is at most one, as shown in Table 6. Then, we compiled

Table 7. The degree of direct influence.

Aspects	Sum of Row	Sum of Column	Sum of Row and Column	Importance of Influence
Medical services (MSs)	0.981	0.995	1.976	2
Medical facilities (MFs)	0.981	1.000	1.981	1
Tour planning (TP)	0.991	0.964	1.955	3
Hospitality facilities (HFs)	0.969	0.964	1.933	4

by adding rows and columns. The sum of the rows and columns for “medical facilities (MF)” is 1.981, the most essential influence aspect. On the other hand, the sum of rows and columns for “hospitality facilities (HF)” is 1.933, which is the least essential influence aspect, as shown in Table 7.

$$D=sA,\begin{array}{cc}& s>0\end{array},$$

(1)

where

$$\begin{gathered} s=\underset{i,j}{\mathbf{min}}[1/\underset{1\le i\le n}{\mathbf{max}}{\displaystyle \sum _{j=1}^n{a}_{ij},1/\underset{1\le j\le n}{\mathbf{max}}{\displaystyle \sum _{i=1}^n{a}_{ij},}}]\begin{array}{c}i,j=1,2,\dots ,n\end{array} \\ \mathrm{where}D={[x_{ij}]}_{n\times n},\mathrm{when}0<{\displaystyle \sum _{j=1}^n{x}_{ij}\le 1}\mathrm{or}0<{\displaystyle \sum _{i=1}^n{x}_{ij}\le 1},\mathrm{and}{\displaystyle \sum _{j=1}^n{x}_{ij}}\mathrm{or} \\ {\displaystyle \sum _{i=1}^n{x}_{ij}}\mathrm{equal}1,\mathrm{but}\mathrm{not}\mathrm{all}\mathrm{cases}.\mathrm{Thus},\mathrm{we}\mathrm{can}\mathrm{guarantee}\underset{m\to \infty }{\mathbf{lim}}{X}^m={[0]}_{n\times n}. \end{gathered}$$

(2)

(3)

Evaluate the indirect influence matrix

The indirect influence matrix can be obtained by Equation (3), as shown in

Table 8. The indirect influence matrix (ID).

Aspects	MS	MF	TP	HF	Total
Medical services (MSs)	12.538	12.491	12.148	12.156	49.334
Medical facilities (MFs)	12.445	12.584	12.148	12.158	49.335
Tour planning (TP)	12.555	12.597	12.316	12.238	49.705
Hospitality facilities (HFs)	12.346	12.391	12.027	12.119	48.883
Total	49.884	50.063	48.638	48.671	-

.

$$ID={\displaystyle \sum _{i=2}^{\infty }{D}^i}=D^2{(I-D)}^{-1}$$

(3)

(4)

Determine the full influence matrix

The full influence matrix (T) can be obtained through Equations (4) or (5), as illustrated in

Table 9. The full influence matrix (T).

Aspects	MS	MF	TP	HF	d
Medical services (MSs)	12.538	12.844	12.462	12.470	50.315
Medical facilities (MFs)	12.801	12.584	12.462	12.469	50.316
Tour planning (TP)	12.877	12.927	12.316	12.577	50.696
Hospitality facilities (HFs)	12.663	12.708	12.362	12.119	49.852
r	50.879	51.063	49.601	49.635	-

. The T (full influence matrix) includes multiple elements, as shown in Equation (6). In Equations (7) and(8), $d_i$ was the sum vector of the row value, and $r_i$ was the sum vector of the column value; then, let $i=j$, and {$d_i+r_i$} is the sum vector of the row value plus sum vector of the column value. As {$d_i+r_i$} (sum of the row value plus the sum of the column value) is higher, the relationship of the aspect/criterion is stronger. {$d_i-r_i$} (sum of the row value minus the sum of the column value) indicates the status of the net influence relationship. If $d_i-r_i$ > 0, this means that the degree of influence on others is larger than the degree of influence; otherwise, $d_i-r_i$ < 0.

$$T=D+ID={\displaystyle \sum _{i=1}^{\infty }{D}^i}$$

(4)

$$T={\displaystyle \sum _{i=1}^{\infty }{D}^i=D{(I-D)}^{-1}}$$

(5)

$$\begin{array}{cc}T=[t_{ij}]& i,j=1,2,\dots ,n\end{array}$$

(6)

$$d=d_{n\times 1}={[{\displaystyle \sum _{j=1}^n{t}_{ij}}]}_{n\times 1}=(d_1,\dots ,d_i,\dots ,d_n)$$

(7)

$$r=r_{n\times 1}=[{\displaystyle \sum _{i=1}^n{t}_{ij}}{{]}^{\prime }}_{1\times n}=(r_1,\dots ,r_j,\dots ,r_n)$$

(8)

The medical facilities (MFs) aspect has the highest degree of full influence ($d_2+r_2$ = 101.379). The tour planning (TP) aspect has the highest net influence ($d_3-r_3$ = 1.095). In

Table 10. The degree of full influence.

Aspects	{d}	{r}	{d + r}	{d − r}
Medical services (MSs)	50.315	50.879	101.194	−0.565
Medical facilities (MFs)	50.316	51.063	101.379	−0.747
Tour planning (TP)	50.696	49.601	100.297	1.095
Hospitality facilities (HFs)	49.852	49.635	99.487	0.217

, the order of other net influences is listed as follows: hospitality facilities (HsF) aspect ($d_4-r_4$ = 0.217), medical services (MSs) aspect ($d_1-r_1$ = −0.565), and last, the medical facilities (MFs) aspect ($d_2-r_2$ = −0.747).

(5)

Determine the NRM (network relation map)

Respondents evaluated the level of influence of each aspect/criterion using the DEMATEL technique. Thus, the $T_{net}$ (net influence matrix) can be gained by Equation (9). The net influence matrix ($T_{net}$) contains the lower and upper triangle matrices, and the diagonal values of the net influence matrix are all 0, as illustrated in

Table 11. The net influence matrix for healthcare tourism.

Aspects	MS	MF	TP	HF
Medical services (MSs)	-
Medical facilities (MFs)	−0.043	-
Tour planning (TP)	0.415	0.465	-
Hospitality facilities (HFs)	0.193	0.240	−0.216	-

. Moreover, while the lower and upper triangular matrices are the same, their symbols are the opposite. Therefore, decision-makers need only choose one triangular matrix. Table 11 presents the net influence matrix, and Table 11 shows the net influence matrix by Equation (9). The researchers adopted the values of ($d+r$) and ($d-r$) as X and Y values and drew the NRM (network relation map) by the net influence matrix, as illustrated in Figure 3 and Table 11.

$$T_{net}=[t_{ij}-t_{ji}]i,j\in \{1,2,\dots ,n\}.$$

(9)

This study evaluated the healthcare tourism evaluation system’s NRM (network relation map), as illustrated in Figure 3. The dominant aspects are TP (tour planning) and HFs (hospitality facilities), while the MSs (medical services) and MFs (medical facilities) aspects are subordinate. Based on the NRM (network relation map), the decision-makers can determine the adoption strategies and paths, as presented in Table 11 and Figure 3.

3.4. The APA-NRM Analysis

The APA-NRM analysis consists of the APA (attention and performance analysis) technique and the NRM (network relation map) technique. The APA technique evaluates the aspects/criteria’ level of attention and performance indicators for the healthcare tourism evaluation system, and the APA technique can aid service providers of healthcare tourism in determining aspects/criteria that can be enhanced when the standard performance level is less than the average. Adoption strategy A (continuous strengthening) can be used for the MFs (medical facilities) aspect, and adoption strategy B (status keeping) can be adopted for the TP (tour planning) aspect. Adoption strategy C (progressive development) can be adopted for the MSs (medical service) and MFs (medical facilities) aspects. The APA-NRM technique determines the attention and performance status of the aspects/criteria and can help the decision-maker determine suitable adoption paths. The MSs (medical services) and HFs (hospitality facilities) aspects should be enhanced using the APA technique and the TP (tour planning) and HFs aspects should be the primary dominant aspect. The primary subordinate aspects are MSs (medical services) and MFs (medical facilities). Thus, we can enhance the MSs aspect through the TP (tour planning) and HFs (hospitality facilities) aspects. Moreover, the TP aspect can enhance the HFs (hospitality facilities) aspect, as presented in Figure 4 and

Table 12. The adoption strategies for healthcare tourism.

Aspects	APA			NRM			Strategy
	AI	PI	(AD, PD)	d + r	d − r	(R, D)
Medical services (MS)	−0.439	−0.018	L, L	101.194	−0.565	ID (+, −)	C
Medical facilities (MF)	1.461	1.160	H, H	101.379	−0.747	ID (+, −)	A
Tour planning (TP)	−0.237	0.137	L, H	100.297	1.095	D (+, +)	B
Hospitality facilities (HF)	−0.786	−1.279	L, L	99.487	0.217	D (+, +)	C

Notes: The adoption strategies contain four parts: adoption strategy A (continuous strengthening), adoption strategy B (status keeping), adoption strategy C (progressive development), and adoption strategy D (immediate development).

.

3.5. Establish the Suitable Adoption Paths by AI and PI Ranking

The AI (attention indicator) ranking is $MF\supset TP\supset MS\supset HF$ and the PI (performance indicator) ranking is $MF\supset TP\supset MS\supset HF$ in the suitable path analysis, as presented in

Table 13. The suitable adoption paths of healthcare tourism.

	AI (Attention Indicator)	PI (Performance Indicator)
Rank	MF[1] > TP[2] > MS[3] > HF[4]	MF[1] > TP[2] > MS[3] > HF[4]
Available paths	1. TP[2] → MF[1] {N} 2. TP[2] → MS[3] → MF[1] {Y} 3. TP[2] → HF[4] → MF[1] {Y} 4. TP[2] → HF[4] → MS[3] → MF[1] {Y}	1. TP[2] → MF[1] {N} 2. TP[2] → MS[3] → MF[1] {Y} 3. TP[2] → HF[4] → MF[1] {Y} 4. TP[2] → HF[4] → MS[3] → MF[1] {Y}
Suitable adoption paths	2. TP → MS → MF 3. TP → HF → MF 4. TP → HF → MS → MF

. There are four adoption paths (TP → MF; TP → MS → MF; TP → HF → MF; TP → HF → MS → MF) in the service system of healthcare tourism using the NRM technique. The advantage aspects/criteria can strengthen the disadvantage aspects/criteria based on the aspects/criteria rank of AI (attention indicator) and PI (performance indicator). The AI (attention indicator) ranking is $MF\supset TP\supset MS\supset HF$, and the TP (tour planning) aspect can affect the MSs (medical services) using the second available path (TP[2] → MS[3] → MF[1]), and the TP aspect can affect the HFs (hospitality facilities) aspect by the third available path (TP[2] → HF[4] → MF[1]), as shown in Table 13. The TP aspect can affect the HFs aspect using the fourth available path (TP[2] → HF[4] → MS[3] → MF[1]), as presented in Table 13.

The PI (performance indicator) ranking is $MF\supset TP\supset MS\supset HF$, and the TP aspect can improve the MSs aspect based on the second available path (TP[2] → MS[3] → MF[1]), and the TP aspect can affect the HFs aspect through the third available path (TP[2] → HF[4] → MF[1]), as shown in Table 13. In addition, the TP aspect can strengthen the HFs aspect using the fourth available path (TP[2] → HF[4] → MS[3] → MF[1]). Therefore, the APA-NRM technique combines the available paths of AI (attention indicator) and PI (performance indicator), and the suitable adoption paths are presented in Table 13. Because the research result shows the same AI (attention indicator) and PI (performance indicator) available paths, the suitable adoption paths include the three adoption paths (TP → MS → MF, TP → HF → MF, TP → HF → MS → MF), as presented in Table 13.

4. The APA-NRM Analysis for the Healthcare Tourism

This study presents the APA-NRM technique for healthcare tourism. We analyzed attention and performance status using paper/online questionnaires. The aspects/criteria of healthcare tourism evaluation systems can be strengthened by the APA technique (attention performance analysis) and the identification of adoption strategies by the NRM technique (network relationship map). This study combined the APA and NRM methods to evaluate the adoption strategies and suitable adoption paths for healthcare tourism. This study presents the results of each analysis of APA-NRM in Section 4.1. In addition, the researchers discussed the adoption strategy in Section 4.2 and proposed directions for healthcare tourism.

4.1. Determine the Adoption Strategy and Suitable Adoption Paths

The APA-NRM technique was introduced in this sub-section for the evaluation system of healthcare tourism. The APA technique can evaluate the attention and performance status for each aspect/criterion and determine the network relation structure through the NRM technique. The APA-NRM technique can assess the adoption strategy and suitable adoption path for the evaluation system of healthcare tourism.

4.1.1. The Aspect of MSs (Medical Services)

In the MSs (medical services) aspect, this study establishes the adoption strategies and a suitable adoption path based on the APA-NRM technique. It combines the analytic results of APA and NRM analysis, as shown in Figure 5 and

Table 14. The adoption strategies of the MSs (medical services) aspect.

Aspects	APA			NRM			Strategy
	AI	PI	(AD, PD)	d + r	d − r	(R, D)
Reservation service (MS1)	−1.355	−0.824	L, L	51.145	0.933	D (+, +)	C
Treatment assessment (MS2)	−0.496	−0.247	L, L	51.554	−0.288	ID (+, −)	C
Medical surgery (MS3)	1.174	1.133	H, H	51.992	−0.927	ID (+, −)	A
Postoperative recovery (MS4)	−0.815	−0.118	L, L	51.144	0.282	D (+, +)	C

Note 1: The adoption strategies contain four parts: adoption strategy A (continuous strengthening), adoption strategy B (status keeping), adoption strategy C (progressive development), and adoption strategy D (immediate development).

. Then, the net influence matrix of the MSs aspect is presented in

Table 15. The net influence matrix of the MSs (medical services) aspect.

Aspects	MS1	MS2	MS3	MS4
Reservation service (MS1)	-
Treatment assessment (MS2)	−0.305	-
Medical surgery (MS3)	−0.466	−0.158	-
Postoperative recovery (MS4)	−0.163	0.142	0.303	-

. Based on the APA analysis, the criteria of MS1 (reservation service), MS2 (treatment assessment), and MS4 (postoperative recovery) are the attention indicators lower than the average attention level (AI < 0), and the performance indicator is also lower than the average performance level (PI < 0). Consequently, these three criteria (MS1, MS2, and MS4) should be strengthened when their attention indicator is higher than the average level, as shown in Figure 5 and Table 14. Based on the NRM analysis, the MS1 (reservation service) and MS4 (postoperative recovery) criteria are the positive net influence effect ($d-r>0$), so they can enhance the MS2 (treatment assessment) criterion through the criteria of MS1 (reservation service) and MS4 (postoperative recovery), as illustrated in Figure 5 and Table 14. Two adoption strategies are present in Table 14; adoption strategy A (continuous strengthening) can be adopted for MS3 (medical surgery) (AI > 0, PI > 0). Adoption strategy C (progressive development) can be adopted for the criteria of MS1, MS2, and MS4 (AI < 0, and PI < 0). The criteria of MS1, MS2 and MS4 are in the third quadrant (L, L), so these three criteria should be strengthened. The criterion of MS1 and MS4 can enhance the MS2 criterion, but the MS1 criterion can only be enhanced by itself, as shown in Figure 5 and Table 14.

The ranking of the AI (attention indicator) is $MS3\supset MS2\supset MS4\supset MS1$ and the ranking of the PI (performance indicator) is $MS3\supset MS4\supset MS2\supset MS1$, based on the APA technique, as shown in

Table 16. The suitable adoption paths of the MSs (medical services) aspect.

	AI (Attention Indicator)	PI (Performance Indicator)
Rank	MS3[1] > MS2[2] > MS4[3] > MS1[4]	MS3[1] >MS4[2] > MS2[3] > MS1[4]
Available paths	1. MS1[4] → MS3[1]{N} 2. MS1[4] → MS2[2] → MS3[1]{N} 3. MS1[4] → MS4[3] → MS3[1]{N} 4. MS1[4] → MS4[3] → MS2[2] → MS3[1]{N}	1. MS1[4] → MS3[1]{N} 2. MS1[4] → MS2[3] → MS3[1]{N} 3. MS1[4] → MS4[2] → MS3[1]{N} 4. MS1[4] → MS4[2] → MS2[3] → MS3[1]{Y}
Suitable adoption paths	-

. There are four paths (MS1 → MS3; MS1 → MS2 → MS3; MS1 → MS4 → MS3; MS1 → MS4 → MS2 → MS3) in the MSs (medical services) aspect by the NRM technique. Therefore, we can use the advantageous aspects/criteria to enhance the disadvantageous aspects/criteria through the aspects/criteria rank of the AI (attention indicator) and PI (performance indicator). The ranking of the AI (attention indicator) is $MS3\supset MS2\supset MS4\supset MS1$. There is no available path in the AI (attention indicator). The ranking of the PI (performance indicator) is $MS3\supset MS4\supset MS2\supset MS1$. The MS4 (postoperative recovery) criterion can enhance the MS2 (treatment assessment) criterion based on the fourth available path (MS1[4] → MS4[2] → MS2[3] → MS3[1]). Therefore, the APA-NRM technique combines the available paths of the AI (attention indicator) and PI (performance indicator); and the suitable adoption paths can be determined through the APA-NRM technique, as illustrated in Table 16. This study integrates the available paths of AI and PI for the MSs (medical services) aspect, so there are no suitable adoption paths, as illustrated in Table 16.

4.1.2. The Aspect of MF (Medical Facilities)

In the MFs (medical facilities) aspect, this study establishes the adoption strategies and a suitable adoption path through the APA-NRM technique. It combines the analytic results of APA and NRM analysis, as presented in Figure 6 and

Table 17. The adoption strategies of the MFs (medical facilities) aspect.

Aspects	APA			NRM			Strategy
	AI	PI	(AD, PD)	d + r	d − r	(R, D)
Surgical equipment (MF1)	1.591	0.877	H, H	146.323	−0.451	ID (+, −)	A
Diagnosis facilities (MF2)	1.296	1.069	H, H	145.934	−1.176	ID (+, −)	A
Medical equipment (MF3)	1.517	1.839	H, H	147.370	−0.169	ID (+, −)	A
Medical examination facilities (MF4)	0.560	−0.183	H, L	144.526	1.796	D (+, +)	D

Note 1: The adoption strategies contain four parts: adoption strategy A (continuous strengthening), adoption strategy B (status keeping), adoption strategy C (progressive development), and adoption strategy D (immediate development).

. Then, the net influence matrix of the MFs aspect is shown in

Table 18. The net influence matrix of MFs (medical facilities).

Aspects	MF1	MF2	MF3	MF4
Surgical equipment (MF1)	-
Diagnosis facilities (MF2)	−0.182	-
Medical equipment (MF3)	0.072	0.253	-
Medical examination facilities (MF4)	0.561	0.740	0.495	-

. Based on the APA analysis, the criterion of MF4 (medical examination facilities) is that the attention indicators are higher than the average attention level (AI > 0), and the performance indicator is lower than the average performance level (PI < 0). Consequently, the MF4 should be strengthened because its attention indicator is higher than the average level. Based on the NRM analysis, the criterion of MF4 (medical examination facilities) is the positive net influence effect ($d-r>0$), so they can enhance the criteria of MF1 (surgical equipment), MF2 (diagnosis facility), and MF3 (medical facility) by the MF4 criterion, as shown in Figure 6 and Table 17. Two adoption strategies are shown in Table 17; adoption strategy A (continuous strengthening) can be adopted for the criteria of MF1 (surgical equipment), MF2 (diagnosis facilities), and MF3 (medical equipment) (AI > 0, PI > 0). Adoption strategy D (immediate development) can be adopted for the MF4 (medical examination facilities) criterion (AI > 0, and PI < 0). The MF4 criterion is located in the fourth quadrant (H, L), so the criterion should be strengthened. The MS4 criterion can only be enhanced by itself, as presented in Figure 6 and Table 17.

The ranking of the AI (attention indicator) is $MF1\supset MF3\supset MF2\supset MF4$ and the ranking of the PI (performance indicator) is $MF3\supset MF2\supset MF1\supset MF4$, as shown in

Table 19. The suitable adoption paths of the MFs (medical facilities) aspect.

	AI (Attention Indicator)	PI (Performance Indicator)
Rank	MF1[1] > MF3[2] > MF2[3] > MF4[4]	MF3[1] > MF2[2] > MF1[3] > MF4[4]
Available paths	1. MF4[4] → MF2[3]{N} 2. MF4[4] → MF1[1] → MF2[3]{Y} 3. MF4[4] → MF3[2] → MF2[3]{Y} 4. MF4[4] → MF3[2] → MF1[1] → MF2[3]{Y}	1. MF4[4] → MF2[2] {N} 2. MF4[4] → MF1[3] → MF2[2]{N} 3. MF4[4] → MF3[1] → MF2[2]{Y} 4. MF4[4] → MF3[1] → MF1[3] → MF2[2]{Y}
Suitable adoption paths	3. MF4 → MF3 → MF2 4. MF4 → MF3 → MF1 → MF2

. The four adoption paths (MF4 → MF2; MF4 → MF1 → MF2; MF4 → MF3 → MF2; MF4 → MF3 → MF1 → MF2) were adopted for the MFs (medical facilities) aspect based on the NRM technique. The AI (attention indicator) ranking is $MF1\supset MF3\supset MF2\supset MF4$. The MF1 (surgical equipment) criterion can affect the MF2 (diagnosis facility) criterion by the second available path (MF4[4] → MF1[1] → MF2[3]). The MF3 (medical facility) criterion can enhance the MF2 criterion through the third available path (MF4[4] → MF3[2] → MF2[3]). The MF1 criterion can enhance the MF2 criterion using the fourth available path (MF4[4] → MF3[2] → MF1[1] → MF2[3]). The PI (performance indicator) ranking is $MF3\supset MF2\supset MF1\supset MF4$. The MF3 criterion can affect the MF2 criterion based on the third available path (MF4[4] → MF3[1] → MF2[2]). Further, the MF3 criterion can enhance the MF1 criterion based on the fourth available path (MF4[4] → MF3[1] → MF1[3] → MF2[2]), as shown in Table 19. Therefore, the APA-NRM technique combines the available paths of the AI (attention indicator) and PI (performance indicator); the suitable adoption paths are shown in Table 19. The suitable adoption paths include the two suitable adoption paths (MF4 → MF3 → MF2; MF4 → MF3 → MF1 → MF2), as shown in Table 19.

4.1.3. The Aspect of TP (Tour Planning)

In the TP (tour planning) aspect, this study establishes the adoption strategies and suitable adoption paths using the APA-NRM technique. It combines the analytic results of APA and NRM analysis, as shown in Figure 7 and

Table 20. The adoption strategies of the TP (tour planning) aspect.

Aspects	APA			NRM			Strategy
	AI	PI	(AD, PD)	d + r	d − r	(R, D)
Intercity sightseeing (TP1)	0.314	0.267	H, H	174.966	0.331	D (+,+)	A
City tour (TP2)	−0.275	−0.632	L, L	175.911	0.337	D (+,+)	C
Reception service (TP3)	−0.348	0.684	L, H	177.304	−0.401	ID (+,−)	B
Traffic connection (TP4)	−0.496	0.106	L, H	176.637	−0.267	ID (+,−)	B

Note1: The adoption strategies contain four parts: adoption strategy A (continuous strengthening), adoption strategy B (status keeping), adoption strategy C (progressive development), and adoption strategy D (immediate development).

. Then, the net in fluence matrix of the TP aspect is shown in

Table 21. The net influence matrix of TP (tour planning) aspect.

Aspects	TP1	TP2	TP3	TP4
Intercity sightseeing (TP1)	-
City tour (TP2)	−0.003	-
Reception service (TP3)	−0.181	−0.186	-
Traffic connection (TP4)	−0.147	−0.154	0.034	-

. Based on the APA analysis, the TP2 (city tour) criterion has attention indicators lower than the average attention level (AI < 0), and the performance indicator is also lower than the average performance level (PI < 0). Consequently, the TP2 (city tour) criterion should be strengthened when its attention indicator is higher than the average level, as shown in Figure 7 and Table 20. Based on NRM analysis, the criteria of TP1 (intercity sightseeing) and TP2 (city tour) have a positive net influence effect ($d-r>0$), so they can enhance the criteria of TP3 (reception service) and TP4 (traffic connection) through the TP1 and TP2 criteria, as illustrated in Figure 7 and Table 20. Three adoption strategies are presented in Table 20; adoption strategy A (continuous strengthening) can be adopted for the criteria of TP1 (intercity sightseeing) (AI > 0, PI > 0). Adoption strategy B (status keeping) can be adopted for the TP3 (reception service) and TP4 (traffic connection) criteria (AI < 0, and PI > 0). Adoption strategy C (progressive development) can be adopted for the TP2 (city tour) criterion (AI < 0, and PI < 0). The TP2 criterion is located in the third quadrant (L, L), so the criterion should be strengthened. The TP2 criterion can be enhanced by TP1, as presented in Figure 7 and Table 20.

The AI (attention indicator) ranking is $TP1\supset TP2\supset TP3\supset TP4$, and the PI (performance indicator) ranking is $TP3\supset TP1\supset TP4\supset TP2$, as shown in

Table 22. The suitable adoption paths of the TP (tour planning) aspect.

	AI (Attention Indicator)	PI (Performance Indicator)
Rank	TP1[1] > TP2[2] > TP3[3] > TP4[4]	TP3[1] > TP1[2] > TP4[3] > TP2[4]
Available paths	1. TP1[1] → TP3[3] {Y} 2. TP1[1] → TP4[4] → TP3[3] {Y} 3. TP1[1] → TP2[2] → TP3[3] {Y} 4. TP1[1] → TP2[2] → TP4[4] → TP3[3] {Y}	1. TP1[2] → TP3[1] {N} 2. TP1[2] → TP4[3] → TP3[1] {Y} 3. TP1[2] → TP2[4] → TP3[1] {Y} 4. TP1[2] → TP2[4] → TP4[3] → TP3[1] {Y}
Suitable adoption paths	2. TP1 → TP4 → TP3 3. TP1 → TP2 → TP3 4. TP1 → TP2 → TP4 → TP3

. The four paths (TP1 → TP3; TP1 → TP4 → TP3; TP1 → TP2 → TP3; TP1 → TP2 → TP4 → TP3) can be adopted for the TP (tour planning) aspect based on the NRM technique. The AI (attention indicator) ranking is $TP1\supset TP2\supset TP3\supset TP4$. The TP1 (intercity sightseeing) criterion can enhance the TP3 (reception service) based on the first available path (TP1[1] → TP3[3]). The TP1 criterion can enhance the TP4 (traffic connection) criterion based on the second available path (TP1[1] → TP4[4] → TP3[3]), as shown in Table 22. The TP1 criterion can enhance the TP2 criterion, and the TP2 criterion can enhance the TP3 criterion based on the third available path (TP1[1] → TP2[2] → TP3[3]), and the TP1 criterion can enhance the TP2 criterion, and the TP2 criterion can enhance the TP4 criterion based on the fourth available path (TP1[1] → TP2[2] → TP4[4] → TP3[3] ), as shown in Table 22. The PI (performance indicator) ranking is $TP3\supset TP1\supset TP4\supset TP2$. The TP1 criterion can affect the TP4 criterion based on the second available path (TP1[2] → TP4[3] → TP3[1]). The TP1 criterion can improve the TP2 criterion based on the third available path (TP1[2] → TP2[4] → TP3[1]). Further, the TP1 criterion can enhance the TP2 criterion based on the fourth available path (TP1[2] → TP2[4] → TP4[3] → TP3[1]), as presented in Table 22. Therefore, the APA-NRM technique combines the available paths of the AI (attention indicator) and PI (performance indicator); the suitable adoption paths are shown in Table 22. The suitable adoption paths include (TP1 → TP4 → TP3; TP1 → TP2 → TP3; TP1 → TP2 → TP4 → TP3), as presented in Table 22.

4.1.4. The Aspect of HT (Hospitality Facilities)

In the HTs (hospitality facilities) aspect, this study established the adoption strategies and suitable adoption path using the APA-NRM technique. It combined the analytic results of APA and NRM analysis, as presented in Figure 8 and

Table 23. The adoption strategies of HFs (hospitality facilities) aspect.

Aspects	APA			NRM			Strategy
	AI	PI	(AD, PD)	d + r	d − r	(R, D)
Accommodation facilities (HF1)	0.290	0.427	H, H	198.268	0.851	D (+, +)	A
Restaurant facilities (HF2)	−0.471	−1.306	L, L	196.424	1.383	D (+, +)	C
Emergency treatment (HF3)	−1.011	−1.466	L, L	197.027	−1.677	ID (+, −)	C
Medical connection (HF4)	−1.477	−1.627	L, L	198.132	−0.557	ID (+, −)	C

Note1: The adoption strategies contain four parts: adoption strategy A (continuous strengthening), adoption strategy B (status keeping), adoption strategy C (progressive development), and adoption strategy D (immediate development).

. Then, the net influence matrix of the HFs aspect is shown in

Table 24. The net influence matrix of the HFs (hospitality facilities) aspect.

Aspects	HF1	HF2	HF3	HF4
Accommodation facilities (HF1)	-
Restaurant facilities (HF2)	0.138	-
Emergency treatment (HF3)	−0.635	−0.760	-
Medical connection (HF4)	−0.354	−0.485	0.282	-

. Based on the APA analysis, the criteria of HF2 (restaurant facilities), HF3 (emergency treatment), and HF4 (medical connection) are the attention indicators that are lower than the average attention level (AI < 0), and the performance indicator is also lower than the average performance level (PI < 0). Consequently, these three criteria (HF2, HF3, and HF4) should be strengthened when their attention indicator is higher than the average level, as shown in Figure 8 and Table 23. Based on the NRM analysis, the criteria of HF2 (restaurant facilities) and HF1 (accommodation facilities) are the positive net influence effect ($d-r>0$), so they can enhance the criteria of HF4 (medical connection) and HF3 (emergency treatment) by the HF1 and HF2 criteria, as presented in Figure 8 and Table 23. Two adoption strategies are shown in Table 23; adoption strategy A (continuous strengthening) can be adopted for the HF1 (accommodation facilities) criterion (AI > 0, PI > 0). Adoption strategy C (progressive development) can be adopted for the criteria of HF2 (restaurant facilities), HF3 (emergency treatment), and HF4 (medical connection) (AI < 0, and PI < 0). The HF2, HF3, and HF4 criteria are located in the third quadrant (L, L), so these three criteria should be strengthened. The criteria of HF1 and HF2 can enhance the HF3 and HF4 criteria. The HF2 criterion can only be enhanced by itself, as presented in Figure 8 and Table 23.

The AI (attention indicator) ranking is $HP1\supset HP2\supset HP3\supset HP4$, and the ranking of the PI (performance indicator) is $HP1\supset HP2\supset HP3\supset HP4$, as shown in

Table 25. The suitable adoption paths of the HFs (hospitality facilities) aspect.

	AI (Attention Indicator)	PI (Performance Indicator)
Rank	HF1[1] > HF2[2] > HF3[3] > HF4[4]	HF1[1] > HF2[2] > HF3[3] > HF4[4]
Available paths	1. HF2[2] → HF3[3]{Y} 2. HF2[2] → HF4[4] → HF3[3]{Y} 3. HF2[2] → HF1[1] → HF3[3]{Y} 4. HF2[2] → HF1[1] → HF4[4] → HF3[3]{Y}	1. HF2[2] → HF3[3]{Y} 2. HF2[2] → HF4[4] → HF3[3]{Y} 3. HF2[2] → HF1[1] → HF3[3]{Y} 4. HF2[2] → HF1[1] → HF4[4] → HF3[3]{Y}
Suitable adoption paths	1. HF2 → HF3 2. HF2 → HF4 → HF3 3. HF2 → HF1 → HF3 4. HF2 → HF1 → HF4 → HF3

. The four paths (HF2 → HF3; HF2 → HF4 → HF3; HF2 → HF1 → HF3; HF2 → HF1 → HF4 → HF3) were adopted for the HFs (hospitality facilities) aspect based on the NRM technique. The AI (attention indicator) ranking is $HP1\supset HP2\supset HP3\supset HP4$. The HF2 (restaurant facilities) criterion can enhance the HF3 (emergency treatment) criterion based on the first available path (HF2[2] → HF3[3]). The HF2 criterion can improve the HF4 (medical connection) criterion based on the second available path (HF2[2] → HF4[4] → HF3[3]). The HF1 criterion can improve the HF3 criterion, based on the third available path (HF2[2] → HF1[1] → HF3[3]). The HF1 criterion can affect the HF4 criterion based on the fourth available path (HF2[2] → HF1[1] → HF4[4] → HF3[3]), as shown in Table 25. The PI (performance indicator) ranking is $HP1\supset HP2\supset HP3\supset HP4$. The HF2 criterion can enhance the HF3 criterion based on the first available path (HF2[2] → HF3[3]), as shown in Table 25. The HF2 criterion can affect the HF4 criterion through the second available path (HF2[2] → HF4[4] → HF3[3]). The HF1 criterion can enhance the HF3 criterion based on the third available path (HF2[2] → HF1[1] → HF3[3]). Further, the HF1 criterion can affect the HF4 criterion based on the fourth available path (HF2[2] → HF1[1] → HF4[4] → HF3[3]), as shown in Table 25. Therefore, the APA-NRM technique integrates the available paths of the AI (attention indicator) and PI (performance indicator); the suitable adoption paths are shown in Table 25. The suitable adoption paths are the four suitable adoption paths (HF2 → HF3; HF2 → HF4 → HF3; HF2 → HF1 → HF3; HF2 → HF1 → HF4 → HF3), as shown in Table 25.

4.2. Discussion

In recent years, the attractiveness of medical tourism destinations has drawn increasing attention from travelers and patients. Some studies explored the factors influencing patient flow to Austria and proposed a comprehensive framework for future comparison analyses. The researchers employed literature reviews, secondary data analysis, site analysis, and interviews with patients and healthcare professionals. This study revealed that outbound medical travel from Austria is primarily driven by access, affordability, and proximity. In contrast, inbound medical travel is driven by the inadequate medical infrastructure and poor medical and service quality in source countries. Healthcare providers differ based on the extent of their involvement in medical tourism. Although specific to Austria, these findings contributed to a broader understanding of Europe’s current medical travel patterns. Unlike other studies, this study examined Austrian and international medical travel, providing crucial insights into the development of European health policy [50]. Recent research investigated the key determinants of service satisfaction and evaluation processes among Bangladeshi medical tourists in India. The researchers conducted a cross-sectional study involving 388 Bangladeshi patients who sought medical treatment in India. This study revealed several critical findings through comprehensive surveys gathering data on medical tourism experiences, health conditions, and demographic profiles. Statistical analysis identified healthcare facilities and services as the primary factors influencing patient satisfaction, with location, cost considerations, and rural settings also playing significant roles. This study highlighted that most participants were self-referred patients, with cardiac conditions and cancer being the predominant medical concerns. The researchers recommended interventions to enhance medical tourism satisfaction, including improving healthcare provider training, addressing language barriers, and reducing travel and treatment expenses [51].

Based on research findings from Austria, patient flows in medical tourism are influenced by accessibility, medical costs, and proximity. Outbound medical travel is mainly driven by the accessibility and affordability of domestic healthcare, while inbound travel is due to inadequate medical infrastructure and service quality in source countries. Improving accessibility, rationalizing medical costs, and enhancing transport convenience are crucial for advancing medical services. Additionally, a study of 388 Bangladeshi patients seeking treatment in India found that medical facilities and services are the most critical factors affecting satisfaction, with location, cost, and environment influencing choices. Recommendations include strengthening healthcare training, reducing language barriers, and lowering costs to improve satisfaction further. This study identified four dimensions (medical services, medical facilities, tour planning, and hospitality facilities) and sixteen evaluation criteria for medical tourism assessment based on expert interviews and a literature review. The APA-NRM approach can be proposed by integrating APA (attention and performance analysis) and NRM (network relation map). APA results showed that medical facilities (MF) are in the first quadrant (high attention, high performance) and should be continuously strengthened (adoption strategy A). Tour planning (TP) is in the second quadrant (low attention, high performance) and should be status-keeping (adoption strategy B). Medical services (MSs) and hospitality facilities (HFs) are in the third quadrant (low attention, low performance). They should adopt progressive development (adoption strategy C) to enhance Taiwan’s international competitiveness in medical tourism services. In conclusion, to improve its global competitiveness in medical tourism, Taiwan should strengthen medical facilities, optimize tour planning, and improve medical services and hospitality facilities. At the same time, improving healthcare service training, reducing language and communication barriers, and rationalizing medical costs are critical to increasing overall service satisfaction and international appeal.

Based on the research results, the MS3 (medical surgery) criterion is in the first quadrant for the MSs (medical services) aspect. In contrast, the MS1 (reservation service), MS2 (treatment assessment), and MS4 (postoperative recovery) criteria are located in the third quadrant. Adoption strategy A (continuous strengthening) can be applied to the MS3 (medical surgery) criterion, and adoption strategy C (progressive development) can be adapted to the MS1, MS2, and MS4 criteria. Therefore, no suitable adoption path exists for the MSs (medical services) aspect, as shown in

Table 26. The suitable adoption paths for healthcare tourism.

Aspects	Suitable Adoption Paths
MSs (medical services)	-
MFs (medical facilities)	3. MF4 → MF3 → MF2 4. MF4 → MF3 → MF1 → MF2
TP (tour planning)	2. TP1 → TP4 → TP3 3. TP1 → TP2 → TP3 4. TP1 → TP2 → TP4 → TP3
HFs (hospitality facilities)	1. HF2 → HF3 2. HF2 → HF4 → HF3 3. HF2 → HF1 → HF3 4. HF2 → HF1 → HF4 → HF3

. Authorities and service providers should continue to enhance the quality of medical services, as outstanding medical surgery and comprehensive care remain the key factors in attracting health and medical tourism visitors or patients. At the same time, it is essential to gradually improve appointment systems, treatment evaluation, and postoperative recovery services in medical institutions. A well-designed appointment process makes arranging their trips more convenient for travelers or patients. At the same time, practical treatment evaluation and postoperative care can reduce uncertainties during the journey and enhance the overall safety and quality of the travel experience.

A study of tourism destinations explores the medical tourism destinations based on the novel MCDM approach. This study combines the analytic hierarchy process and rough sets to establish a systematic evaluation system of medical tourism destinations. Researchers adopt the rough analytic hierarchy process to evaluate the relative importance of criteria and the rough multi-attributive border approximation area comparison to analyze the alternative sites using the criteria weights. Additionally, this study demonstrates the opposing model based on the Indian medical tourism destinations (cities). The research result points out that the infrastructure quality of healthcare institutions was the critical criterion, followed by skilled human resources, and new job creations. This study finds that Chennai is the best medical tourism destination in India. Finally, this study provides validity testing and comparative analysis for the proposed model and offers valuable suggestions for selecting medical tourism destinations [52]. The Chinese government commenced the aging care reforms for those over 60 in 2005. The aging care reforms focus on (1) long-term aging care, (2) alleviating rural poverty through tourism policies, and (3) creating more employment opportunities and improving local medical facilities. The main success factors of aging, long-term care reforms come from the choice preference of the aged group’s holiday areas and retirement regions. The preference for holiday areas and retirement regions was affected by the pensions, other income, and the care-home facilities. The research results indicate that medical care services were critical for choosing holiday areas and retirement regions. Beijing residents prefer to choose a rural location for retirement. The pensions have little influence on their decision, but the total income will affect their retirement regions [53].

Based on the research results, the criteria of MF1 (surgical equipment), MF2 (diagnosis facility), and MF3 (medical facility) were located in the first quadrant for the MFs (medical facilities) aspect. In contrast, the MF4 (medical examination facilities) criterion was in the fourth quadrant. Adopting strategy A (continuous strengthening) can be used for MF1, MF2, and MF3 criteria. Adoption strategy D (immediate development) can be used for MF4 (medical examination facilities). There are two suitable adoption paths (MF4 → MF3 → MF2; MF4 → MF3 → MF1 → MF2) that were adopted for the MF (medical facilities) aspect, as shown in Table 26. Many diseases are not easily detected in their early stages and can only be discovered through tests and examinations. Therefore, introducing new medical diagnostic facilities is beneficial for detecting and identifying diseases. In addition, continuous upgrades and investments in surgical, diagnostic, and overall medical equipment and facilities can enhance the quality of medical treatment and care provided by medical professionals, and also allow physicians to adopt new surgical approaches that are less burdensome to patients, such as minimally invasive and catheter-based procedures. Furthermore, adopting and mastering these new surgical techniques requires substantial investment in advanced medical equipment and training for related healthcare personnel. Early introduction and investment in advanced medical facilities and equipment are crucial for continuously attracting international medical tourists and patients.

The third suitable adoption path is that the MF4 (medical examination facilities) criterion affects the MF3 (medical facility) criterion, and the MF3 criterion affects the MF2 (diagnosis facility) criterion. Health screening is a key starting point for medical services, enabling early detection of potential health problems and timely treatment. With the growth of wellness tourism, medical institutions have begun to provide more diverse medical screening services. This has increased the demand for medical tests and indirectly increased hospital outpatients and outpatient services. To meet the needs of these new travelers/patients, hospitals have begun to buy new medical equipment and expand diagnostic facilities. This chain effect improved the quality of medical services and created new development opportunities for the health industry. The fourth suitable adoption path is the MF4 (medical examination facilities) criterion, which affects the MF3 (medical facility) criterion, and the MF3 affects the MF1 (surgical equipment) criterion. The criterion of MF1 criterion enhances the MF2 (diagnosis facility) criterion. Health screening plays a key role in the process of medical services. Regular health checks identify potential problems early, and preventive care and timely treatment are possible. This preventive medical model encourages medical institutions to enter wellness tourism by providing comprehensive examination services. The demand for medical examination services has also increased with increasing health awareness. This trend stimulated the growth of hospital outpatient and inpatient services. It encouraged hospitals to introduce advanced medical equipment and surgical facilities, implement minimally invasive surgery capabilities, and establish catheterization procedure facilities. Additionally, some hospitals strengthen healthcare provisions by recruiting experienced medical staff and enhancing investments in diagnostic facilities to improve the overall quality of the services provided to patients and improve the standard of healthcare through the institutions.

Korea’s efforts to develop medical tourism have significantly increased its foreign patient numbers—from 60,201 in 2009 to 321,574 in 2017. While visitor numbers from the U.S., Russia, and the Middle East are growing, Chinese patient numbers have declined, highlighting the impact of cultural differences and international relations. To build a sustainable medical tourism market, this study suggests creating a unique Korean brand by integrating Western and oriental medicine, cultivating global healthcare talents, and tailoring medical services for diverse cultural backgrounds [54]. A study on India’s medical service supply chain identified key factors influencing the value and quality of medical tourism, including healthcare accreditation, reduced surgery wait times, access to information, staff expertise, facility standards, travel risks, patient safety, costs, and holiday options. Insights were drawn from interviews with private hospitals and senior providers, offering actionable recommendations for medical tourism facilitators and service providers [55].

Based on the research results, the TP1 (intercity sightseeing) is located in the first quadrant, and the criteria of TP3 (reception service) and TP4 (traffic connection) are located in the second quadrant for the TP (tour planning) aspect. The TP2 (city tour) criterion is located in the third quadrant. Adoption strategy A (continuous strengthening) can apply to the TP1 (intercity sightseeing) criterion, and adoption strategy B (status keeping) can apply to the TP3 and TP4 criteria. Adoption strategy C (progressive development) can be adopted for the TP2 criterion. There are three suitable adoption paths (TP1 → TP4 → TP3; TP1 → TP2 → TP3; and TP1 → TP2 → TP4 → TP3) for the TP (tour planning) aspect, as shown in Table 26. High-quality reception services and convenient transportation are fundamental to attracting health and medical tourism visitors. To enhance service quality and reduce errors, relevant authorities and service providers are gradually establishing standardized reception procedures and optimizing these processes to ensure consistent and high-quality service experiences. For long-distance travelers or patients, providing convenient shuttle services also helps reduce the hassle of transferring between different modes of public transportation. In addition, offering diverse and varied travel itineraries can make the experience more refreshing for visitors. When planning services, it is crucial to implement differentiated strategies based on the characteristics of each visitor—for example, arranging intercity or regional tours for younger and physically able travelers, while focusing on local city tours or in-depth local experiences for older or less physically able visitors to reduce fatigue and improve overall comfort and satisfaction during their trip period.

The second suitable adoption path is the TP1 (intercity sightseeing) criterion, which can enhance the TP4 (traffic connection) criterion, and TP4 can strengthen the TP3 (reception service) criterion. While travelers/patients undergo health examinations, a travel itinerary helps reduce the stress of these examinations. Traveling across various regions enables them to experience different local histories, cultures, and customs. Consequently, service providers should arrange shuttle services to eliminate the inconvenience of travelers/patients who must plan their public transport. They should also provide a guided reception service to offer travelers/patients a more in-depth local exploration experience. The third suitable adoption path is the TP1 criterion, which affects the TP2 (city tour) criterion, and the TP2 criterion can affect the TP3 (reception service) criterion. Healthcare tourism service providers can provide travelers/patients with more prosperous and diverse travel options. Travelers/patients can arrange long-distance travel and experience interregional city tourism during the waiting period for the health examination report. A suitable city tour or detailed itinerary for medical patients can be made available depending on their physical condition. In addition, through professional guides and reception services, tourists can enjoy a high-quality travel experience. The fourth suitable adoption path is the TP1 criterion, which can affect the TP2 criterion, and the TP2 criterion can enhance the TP4 criterion. The TP4 can strengthen the TP3 criterion. Healthcare tourism service providers can plan various travel options for their clients. Travelers/patients waiting for health examination reports can join city sightseeing excursions in different regions. Depending on their physical condition, they can plan appropriate city excursions or in-depth local excursions. To improve the quality of their services, healthcare tourism providers can provide professional shuttle services, which reduce the inconvenience of public transport and travel fatigue. In addition, thanks to professional guide services, travelers/patients are assured of a high-quality travel experience.

Medical tourism has become a famous and booming market in the world. Taiwan hospitals have excellent medical service quality and ICT (information and communication technology) ability. Thus, Taiwan and Mainland China have similar cultural, geographical, and linguistic proximity, so Taiwan has become a popular medical tourism destination for Chinese patients. Additionally, the Taiwanese government has improved and modified various medical tourism infrastructures, such as marketing policies, visa regulations, and the ICT application of medical services. The Taiwan Medical Travel App (TMT App) was a critical service application for medical travel and can be used on mobile devices by downloading and setting it up. This study explores the usage intention and essential factors driving the Taiwan Medical Travel App (TMT App) through questionnaires and statistical analyses. Additionally, this study also proposes valuable suggestions for improving the Taiwan Medical Travel App (TMT App) and other similar apps [56]. Travelers’ sense of feeling at home has become increasingly important for the accommodation service industry. So, this study explores the factors influencing travelers’ well-being in the medical tourism segment. Researchers analyzed the 320 tourists who stayed at hotel accommodations and the 420 at an Airbnb. This study uses the SEM (structural equation modeling) approach to evaluate the influence of the accommodations’ homescape on the medical tourists’ sense of well-being and feeling at home. This study provides some new viewpoints to discuss the effect of home-like environments on the well-being of particular traveler segments [57].

Based on the research results, HF1 (accommodation facilities) was located in the first quadrant; the criteria of HF2 (restaurant facilities), HF3 (emergency treatment), and HF4 (medical connection) were located in the third quadrant for the HFs (hospitality facilities) aspect. Adoption strategy A (continuous strengthening) can be adopted for the HF1 criterion, and adoption strategy C (progressive development) can be used for HF2, HF3, and HF4. There are four suitable adoption paths (HF2 → HF3; HF2 → HF4 → HF3; HF2 → HF1 → HF3; HF2 → HF1 → HF4 → HF3) for the HFs (hospitality facilities) aspect, as shown in Table 26.

High-quality and comfortable accommodations, along with delicious and diverse food options, are highly sought after by all travelers and are essential factors in attracting health and medical tourists to a destination. When planning itineraries, relevant authorities and service providers must carefully consider the availability of local accommodation and dining resources. Taking Taiwan as an example, national holidays and summer/winter vacations are peak travel periods, making reservations for rooms and meals more difficult and often resulting in higher travel costs. During these times, the remaining accommodation and dining services may also fail to meet the specific needs of health and medical tourists or patients. Therefore, making early reservations or avoiding peak travel periods can help improve overall service quality. Additionally, access to emergency and medical support is vital for health and medical tourists, as unexpected situations during trips often require urgent care. A well-established emergency and medical connection system can significantly enhance the safety of health and medical tourism activities and reduce the impact of unforeseen events.

The HF2 (restaurant facilities) criterion is the first-suitable adoption path, which can enhance the HF3 criterion. The healthcare tourism service provider should include options for meals and accommodations in the itinerary. Dining facilities should be provided at accommodation locations to facilitate convenient meals for health tourism clients. Standardized emergency measures should also be planned to reduce the risk of accidents in their itinerary. The second suitable adoption path is the HF2 (restaurant facilities) criterion, which can enhance the HF4 (medical connection) criterion, and the HF4 criterion can affect the HF3 (emergency treatment) criterion. Healthcare tourism service providers should offer various meal options and choose well-equipped restaurants to improve health tourism dining convenience. For travelers/patients’ safety reasons, service providers should have established partnerships with local medical institutions, develop a comprehensive emergency escort system, and have standard emergency assistance procedures.

The third suitable adoption path is that the HF2 criterion can enhance the HF1 criterion, and the HF1 criterion can enhance the HF3 criterion. Healthcare tourism service providers can improve itinerary convenience. The itinerary plans will provide various food options and select accommodation locations with a comprehensive restaurant. In addition, service providers must consider the local medical care network when selecting accommodation locations, establish partnerships with regional medical care institutions, develop comprehensive emergency escort mechanisms, and formulate emergency assistance procedures. The fourth suitable adoption path is that the HF2 criterion can affect the HF1 criterion, and the HF1 criterion can enhance the HF4 criterion. The HF4 criterion can enhance the HF3 criterion. To improve the quality of health tourism services, service providers must consider the specific nutritional requirements of health-conscious travelers when planning meals and incorporate personalized meal design solutions with unique local ingredients. To meet the needs and convenience of travelers, service providers should evaluate the comfort of the environment and provide various options, such as breakfast and dinner, so that travelers and patients can use breakfast and dinner in hotels and accommodations before or after their departure. To ensure medical safety during the trip, the provider must verify the distribution of nearby medical facilities, confirm emergency routes, and establish a network of cooperation with local medical institutions to facilitate emergency medical evacuation and support when necessary. Finally, developing measures and safety systems for first aid and safety is vital. In addition to standardized first aid and comprehensive reporting procedures, providers should also develop professional medical support mechanisms and well-equipped emergency first aid facilities, as presented in Table 26.

This study determined nine suitable adoption paths across four evaluation systems of healthcare and medical tourism. Among them, the MSs (medical services) aspect lacked suitable adoption paths. The MFs (medical facilities) aspect had two suitable adoption paths (MF4 → MF3 → MF2; MF4 → MF3 → MF1 → MF2). By partnering with health screening and early treatment centers, service providers can offer travelers and patients timely alerts and interventions using medical testing and diagnostic equipment. Therefore, service providers should consider the needs of both travelers and patients and strengthen partnerships with medical hospitals equipped with comprehensive examination facilities. Through collaboration with health screening and early treatment centers, they can deliver early detection and timely intervention for travelers and patients using medical testing and diagnostic equipment. The TP (tour planning) aspect had three suitable adoption paths (TP1 → TP4 → TP3; TP1 → TP2 → TP3; TP1 → TP2 → TP4 → TP3). In other words, for most customers, the primary motivation for choosing healthcare tourism is travel itself. After unwinding and reducing stress, they have the opportunity better to understand their health status through comprehensive medical check-ups, enabling early disease prevention and treatment. As a result, engaging travelers and patients with well-designed itineraries can increase their interest and is a key reason why they opt for healthcare tourism services. Lastly, the HF (hospitality facilities) aspect had four suitable adoption paths (HF2 → HF3; HF2 → HF4 → HF3; HF2 → HF1 → HF3; HF2 → HF1 → HF4 → HF3), as shown in Table 26. Additionally, healthcare tourism providers should address the varied accommodation and dining needs of their clients, offering tailored arrangements such as specific lodging policies or facilities designed for elderly guests. Some providers also offer special meal plans for travelers or patients before medical examinations, helping to minimize inconvenience and enhance the overall travel experience.

5. Conclusions and Recommendations

With advancements in medical technology and improvements in quality of life, life expectancy continues to increase year by year. For the silver generation, longevity is no longer a challenge; a happy and healthy life is their ultimate goal. The emerging healthcare tourism industry focuses on helping the elderly recover from illnesses and discover the joys of life through travel. This technique enhances the health of older adults and enriches their later years, helping them rediscover the meaning and joy of life. This study identified four aspects of the healthcare tourism evaluation system (medical services, medical facilities, tour planning, and hospitality facilities) and sixteen evaluation criteria through expert interviews and literature reviews. This study combines APA (attention and performance analysis) and NRM (network relation map) methods, proposing the APA-NRM approach. APA (attention and performance analysis) evaluates the status of attention and performance indicators for healthcare tourism evaluation systems. According to the APA analysis, medical facilities (MFs), located in the first quadrant (high attention, high performance), should be continuously strengthened (adoption strategy A). Tour planning (TP) is in the second quadrant (low attention, high performance), so keeping the current status is recommended (adoption strategy B). Both medical services (MSs) and hospitality facilities (HFs) are in the third quadrant (low attention, low performance), suggesting a progressive development approach (adoption strategy C). Based on these findings, key development directions and actionable recommendations for healthcare tourism providers are as follows:

(1)

In the APA analysis, travelers/patients pay more attention to MFs (medical facilities) than MSs (medical services), and MFs (medical facilities) have a higher performance than MSs (medical services), which also means that travelers and patients pay attention and choose a comprehensive and excellent healthcare tourism itinerary with nice medical facilities/services. Furthermore, travelers/patients pay more attention to TP (tour planning) than HFs (hospitality facilities), and TP (tour planning) performs better. This result means that travelers and patients will pay attention to and choose medical sightseeing tours (city tours or international tours) with comprehensive transportation services and friendly guide receptions. In the MFs (medical facilities), travelers/patients pay more attention to the criteria of surgical equipment (MF1), diagnosis facilities (MF2), medical equipment (MF3), and medical examination facilities (MF4). However, the performance of the MF4 criterion was less than the average level. Furthermore, MF4 (medical examination facilities) is the dominant criterion in the NRM (network relation map) analysis, while MF2 (diagnostic facilities) is the subordinate aspect. Therefore, service providers must consider the needs of travelers and patients and cooperate further with medical hospitals that have complete medical examination facilities. By collaborating with health screening and early treatment centers, service providers can provide early warning and treatment for travelers and patients with medical tests and examination equipment.

(2)

In the NRM analysis, TP (tour planning) is the dominant aspect of healthcare tourism evaluation systems, while MFs (medical facilities) is the subordinate aspect. The TP (tour planning) aspect can enhance the HFs aspect. Then, the HFs aspect can improve the MSs (medical services) aspect, and the MSs (medical services) aspect can enhance the MFs (medical facilities) aspect. Therefore, we need to improve the overall satisfaction with healthcare tourism services. It is advisable to start with TP (tour planning), then improve HFs (hospitality facilities), and finally strengthen MSs (medical services) and MFs (medical facilities). In other words, most customers’ primary healthcare tourism needs are travel. After relieving stress and relaxing, they can gain a deeper understanding of their current physical condition through a comprehensive full-body check-up and ultimately carry out early prevention and treatment of diseases. Therefore, increasing travelers’ and patients’ interest through itinerary planning will be attractive, which is also why they become healthcare tourism customers. Additionally, healthcare tourism service providers must consider the accommodation and dining needs of different travelers and patients during their trips and customize the arrangements accordingly, such as the accommodation regulations for the elderly and the design and auxiliary facilities required for them. However, some healthcare tourism service providers can offer meal arrangements for travelers/patients before special medical examinations; these special services can reduce the inconvenience of travelers/patients during their trip. In addition, for medical services (MSs) and medical facilities (MFs), although travelers/patients attach more importance to medical facilities (MFs), without good medical services, it is difficult for travelers/patients to trust that service providers are truly addressing the needs of travelers/patients and arranging best suitable medical services and treatments for them.

(3)

In the TP (tour planning), travelers/patients pay more attention to the TP1 (intercity sightseeing) criterion than the TP2 (city tour), TP3 (reception service), and TP4 (traffic connection) criteria. However, the performance of the TP2 (city tour) criterion was less than the average for the performance indicator. Furthermore, the TP1 (intercity sightseeing) criterion is the dominant criterion in the NRM (network relation map) analysis, while TP3 (reception service) is the subordinate aspect. Therefore, healthcare tourism service providers should start by considering travel arrangements. Planning the trip and travel arrangements includes arranging health check-ups, routes, and options for medical treatment for tourists and patients, because high-end health checks and medical treatment hospitals are more suitable for them. However, most high-end health checks and medical treatment hospitals are concentrated in cities and urban areas. At the same time, those with a particular geographical landscape and unique historical and cultural characteristics are mainly located in the surrounding towns and far from the cities. Consequently, integrating tourist and city tours in the city has become a service provider’s challenge. Intercity sightseeing can increase the diversity of the itinerary, while fixed-point tourism can increase the depth of the itinerary and integrate it into local life. Therefore, according to the flexibility of travel time and budgetary arrangements of travelers and patients, it is recommended to provide a variety of itineraries. Those with more time can arrange long-term leisure and wellness trips to a specific place. They can arrange in-depth travel routes to each city for one or more weeks. For those still working, you can arrange a health check-up plan based on the length of your vacation in the city. They can also plan a route to the counties and towns near the city. This can meet the needs of itinerary diversification while reducing travel time. Excessive traveling will increase the burden and fatigue of travelers and patients. It is recommended that passengers and patients travel in specific cars to improve transportation convenience and reduce fatigue. In contrast, we can reduce the inconveniences of travelers/patients using public transit by healthcare tourism service providers with more flexible schedules to reduce the fatigue of passengers/patients.

(4)

Healthcare tourism provides a significant opportunity to enhance the quality of life for middle-aged and elderly people. Combining professional medical care with meaningful travel experiences offers comprehensive solutions for the health and well-being of people in their later years. This study establishes a healthcare tourism evaluation system to explore the interrelationships between various dimensions and further identifies the most suitable adoption paths. Three suitable adoption paths (TP → MS → MF; TP → HF → MF; TP → HF → MS → MF) have been identified for the evaluation system of healthcare tourism. The TP (tour planning) aspect influences the MSs (medical services) aspect, and the MSs aspect enhances the MFs (medical facilities) aspect in the second suitable adoption path. The TP aspect enhances the HFs (hospitality facilities) aspect, and the HFs aspect strengthens the MFs (medical facilities) aspect in the third suitable adoption path. The TP (tour planning) aspect influences the HFs aspect, the HFs aspect affects the MSs aspect, and the MSs aspect affects the MFs aspect in the fourth-suitable adoption path. From these three most suitable adoption paths, it is evident that the TP (tour planning) aspect is the primary dominant aspect, while the MFs (medical facilities) aspect is the central subordinate aspect among the three main travel companion categories (traveling with family/friends, company colleagues, and alone).

(5)

For traveling with family/friends groups, this group typically combines family tourism formats, resulting in the most diverse member composition and requiring consideration of various needs. The advantage is that some members serve as primary caregivers and companions, enabling mutual support. The main purpose is family companionship and reunion, allowing for more relaxed and flexible itinerary planning. Some less structured, in-depth travel at specific locations can increase members’ interaction opportunities. For the traveling with a company colleagues group, this category includes corporate employee trips and incentive travel, and features a more homogeneous group composed primarily of company colleagues and work partners. While some may participate with spouses or companions, most are company members and their families. Short-term itineraries are suitable, and since the age gap is typically smaller than in family travel, more intensive intercity travel can be arranged. Health examinations and tests should be completed early in the journey, allowing members to receive their health examination results afterward. Traveling alone, these groups face more flexibility but are more complex and require health status evaluation. For those in good health and physical condition, companion travel similar to the company colleagues group can be arranged, reducing risks through mutual support during the journey. For elderly or less healthy individuals, location-specific travel with care resources is preferred. Institutional fixed-point travel destinations can arrange experiential exchange activities and typically maintain long-term partnerships with nearby medical institutions to provide emergency response capabilities.

(6)

The current research found three main categories of travel companions for healthcare tourism based on the composition of travel companions (traveling with family/friends groups, traveling with corporate colleagues groups, and traveling alone groups). This study can help to understand the main driving factors for healthcare tourism and the relationship between the driving factors. However, this study considered that subsequent researchers should still explore the healthcare tourism evaluation system based on the different groups. In addition, this study also found that, from the sample statistical analysis, the female sample is the leading group of customers, which is higher than that of the male group. In addition to the fact that women generally live longer than men, they are also more enthusiastic about group travel or group activities. Consequently, health tourism service providers should pay more attention to women’s health tourism demand, understand their preferred travel preferences and related medical needs, and provide diversified travel itinerary design and health examination and testing programs. In addition, analysis of sample age composition shows that traditional market segmentation based on legal retirement age cannot fully meet market demands. When we consider healthcare tourism as a progressive development stage, for the middle-aged group (over 40 years), medical tourists have better physical strength and health condition, but relatively less vacation time and funds available; their wellness tourism focuses primarily on stress relief and health status assessment. Launching wellness tourism packages that mainly include health examinations and screening, along with short-term urban tourism, is recommended. On the other hand, people aged 60 and over, who generally enter the retirement phase or transfer family businesses to the next generation, gradually have enough capital to enjoy retirement because of their financial accumulation. However, their physical condition and strength may not be as strong as that of the middle-aged group. They can, therefore, consider long-term fixed-point deep tourism as the primary focus, together with short-distance in-depth visits to nearby cities and villages.