A Conceptual Framework for Tourism Development and the Evolution of Local Healthcare Systems: International Comparative Cases

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this conceptual manuscript. The paper addresses a timely and policy-relevant issue by examining the co-evolution of tourism development and local healthcare systems through an integrated conceptual framework, supported by contrasting cases from Phuket (Thailand) and Northern Australia. The topic is important for sustainable destination governance, and the three-pillar framework offers a potentially useful organizing lens. However, several areas require clarification and tightening to strengthen the paper’s conceptual contribution and coherence.

Conceptual positioning and contribution

The manuscript would benefit from a sharper articulation of its specific theoretical contribution. While the interdependence between tourism and health systems is well established, it remains unclear what this framework adds beyond existing discussions of tourism impacts on public health and destination resilience. Please explicitly state how the proposed three-pillar model advances theory (e.g., by formalising feedback loops, reframing healthcare as core destination infrastructure, or providing a transferable governance tool).

Key constructs such as “health system resilience,” “tourism pressure pathways,” and “opportunity leverage mechanisms” should be defined more concisely and consistently early in the paper. Clarifying the boundary conditions (destination types or tourism forms where the framework is most applicable) would further strengthen conceptual precision.

Methods and conceptual synthesis

As a conceptual paper, methodological transparency is still important. The Methods section should briefly but clearly describe how the narrative review was conducted (main disciplines covered, types of sources, and selection logic). The current repetition of the Methods text in the Background section should be removed, and Section 3 should focus on substantive conceptual grounding rather than restating design.

Framework clarity

Figure 1 is central to the manuscript’s contribution. Ensure that causal directions and feedback loops are clearly visible and explained in the text. Some elements (e.g., surveillance, governance capacity) appear across multiple pillars; briefly justify their placement to avoid conceptual overlap. The “opportunity leverage mechanisms” pillar would benefit from a clearer equity perspective, explaining how tourism-generated investment can strengthen health systems without exacerbating dualisation or resident disadvantage.

Case illustrations

The Phuket and Northern Australia cases are well chosen and broadly aligned with the framework. However, ensure all case-specific references are accurate and context-appropriate, as some citations appear mismatched. In both cases, more explicitly distinguish tourism-driven demand pressures from pre-existing structural health system constraints to improve analytical clarity and cross-case comparison.

Presentation and references

Minor but important issues require attention: correct duplicated punctuation (e.g., “Keywords: :”), remove template artefacts, and ensure consistent formatting. Several references contain incomplete author listings (“& al.”, “others”) and duplicated DOI prefixes; these should be standardised carefully.

Overall assessment

The manuscript is promising and addresses an under-integrated area in tourism and hospitality research. With clearer articulation of conceptual novelty, removal of redundancy, tighter framework exposition, and careful reference correction, it can make a valuable contribution to debates on sustainable, health-centred destination governance.

Author Response

Comment 1: Conceptual positioning and contribution The manuscript would benefit from a sharper articulation of its specific theoretical contribution…   Response: I thank the reviewer for this important comment. I have substantially revised the Introduction and Discussion to more clearly articulate the manuscript’s theoretical contribution. Rather than claiming novelty in identifying tourism–health interactions per se, I now explicitly position the contribution as a system-level, co-evolutionary conceptual framework that integrates tourism pressure pathways, health system response capacities, and opportunity leverage mechanisms within a single governance-oriented model. The revised manuscript clarifies that the framework contributes by: (i) explicitly modelling feedback loops between healthcare system performance and destination sustainability and competitiveness; (ii) repositioning healthcare systems as core destination infrastructure within sustainable tourism governance; and (iii) offering a transferable analytical structure applicable across contrasting tourism contexts. This refinement strengthens theoretical clarity while maintaining appropriate conceptual scope.

Comment 2: Strengthen construct definitions and framework logic Response: I agree that conceptual precision is essential. Definitions of the key constructs—tourism pressure pathways, health system response capacities, opportunity leverage mechanisms, and feedback loops—have been clarified and consolidated within the Conceptual Framework section. I have also clarified why certain elements (e.g., surveillance and governance capacity) span multiple pillars, reflecting their dual role in mitigating pressure and enabling opportunity.

Comment 3: Methods and conceptual synthesis Response: I appreciate this comment. The Methods section has been revised to clearly define the study as a conceptual synthesis informed by a narrative review, rather than an empirical or systematic review. I now explicitly describe the disciplinary scope of the literature, the relevance-based selection of sources, and the role of the illustrative cases in refining (rather than generating) the framework. This improves transparency while remaining consistent with the aims of a conceptual paper.

Comment 4: Framework clarity and equity perspective Response: I have clarified the logic of the framework by explicitly explaining why certain elements (e.g., surveillance and governance capacity) span multiple pillars, reflecting their dual role in mitigating pressures and enabling opportunity. I have also strengthened the equity perspective within the opportunity leverage mechanisms pillar, emphasising that tourism-related investment can strengthen healthcare systems only when supported by appropriate governance to avoid dualisation and resident disadvantage.

Comment 5: Case illustrations and references Response: I have reviewed all case-specific references to ensure accuracy and contextual relevance. In both cases, I now more clearly distinguish between tourism-driven pressures and pre-existing structural health system constraints, improving analytical clarity and cross-case comparison.

Comment 6: Presentation and references All formatting issues, typographical errors, and reference inconsistencies have been corrected in line with MDPI style.

Reviewer 2 Report

Comments and Suggestions for Authors

This paper is a reviewed article, which is to explore a conceptual framework for understanding what an unknow situation in the local healthcare systems and sustainable development. This paper has also provided two cases as an explained example. Therefore, this paper has an interesting topic for international readers.

 Some of my personal suggestions as following points.

1. The article framework should be revised. Totally, this paper has 10 sections, it is too long (I mean the number of sections)
2. Section 2 is needed to provide a literature review for readers know, which theory are related, especially on the sustainable tourism.
3. And section 3 is more important on the methodology, which data you collected and analyzed. However, this paper is lost this part, it makes this paper should be revised.
4. I have a little understanding that is section 4 and section 5 like a literature review ad a theoretical development. But, it is also part of literature review.
5. Section 7. Governance and Management Implications, it should be in the end of paper, such as section 10 Conclusions.
6. Figure 1 Is good; it is the core in this paper.
7. The section “8.3. Cross-case synthesis and comparative alignment” should be change to section Discussion.
8. The section 10. Conclusion is weakly. This section is to provide what the Implications are explored. And especially, this section has no limitations and future works, that is making this paper has no significant contributions.

 

Totally, this paper has an interesting topic however, its content and framework of paper is needed a rebuilding work.

The first one is the framework of paper, too many sections and sub-sections. It is making the paper is difficult to read. The second one is the section Methodology; it is needed more contents to describe. The reason is this paper is a narrative review or case study, but the data how to conduct is difficult to understand. In doing so, I would like to encourage the author to put the efforts for improving work, since an academic article is needed a detailed explanation for methodology.

Comments for author File: Comments.pdf

Author Response

Thank you for your suggestions and comments. Comment 1: Framework of the paper: Improve structure and reduce fragmentation Response: I appreciate this comment and have undertaken substantial structural refinement. The manuscript has been reorganised into a clear, MDPI-appropriate structure, separating: (i) the conceptual framework and its components; (ii) illustrative cases; and (iii) discussion and conclusions. Redundant sub-sections have been consolidated, numbering inconsistencies resolved, and transitions strengthened. This improves readability without altering the conceptual scope of the paper.

Comment 2: Methodology and data Response: I have clarified that the study is a conceptual synthesis informed by a narrative review, not an empirical case study. The revised Methods section now clearly explains how sources were selected and how the cases function as analytical illustrations, rather than as primary data. I respectfully maintain that expanding the paper into a detailed empirical methodology would not be consistent with its conceptual aims.

Comment 3: Literature review and theoretical grounding Response: Rather than introducing a standalone literature review section, I strengthened theory integration throughout the Introduction, Framework, and Discussion, consistent with conventions for conceptual tourism research. This approach avoids unnecessary repetition while ensuring that key arguments are clearly grounded in tourism governance, sustainability, and health systems literature.

Comment 4: Balance between cases and generalisability Response: I have clarified that Phuket and Northern Australia function as illustrative cases, selected to demonstrate how shared mechanisms operate across contrasting tourism systems rather than to provide symmetric empirical comparison. The revised Discussion explicitly addresses why differences in depth and emphasis reflect structural differences in tourism form, mobility patterns, and health system constraints, rather than analytical imbalance.

Comment 5: Placement of governance, discussion, and conclusion Response: I have adjusted the structure to improve logical flow, strengthening the Discussion and expanding the Conclusion to clearly articulate implications, limitations, and future research directions. This addresses the reviewer’s concern while retaining the conceptual coherence of the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript represents a theoretically relevant and contemporary conceptual work that deals with the relationship between the development of tourism and the evolution of local health systems, a topic that has been treated fragmentarily in tourism and hospitality. The author successfully recognizes an important research gap and positions the health system as a key component of the destination infrastructure, thus clearly distinguishing the work from the dominant economic and market-oriented approaches in the literature. The special value of the work is reflected in the clearly defined concept of the co-evolution of tourism and health systems, as well as in the proposed three-pillar conceptual framework that connects the paths of tourism pressure, the response capacities of the health system and the mechanisms of using development opportunities, with clearly indicated feedback loops towards the destination's reputation and sustainability.

The text is logically structured and theoretically well-grounded, with rich reliance on relevant and contemporary literature in the field of tourism, public health and health policy. A comparative approach through two contrasting cases, Phuket and Northern Australia, contributes to the comprehensibility and practical illustration of the conceptual framework, showing that the same mechanisms operate differently in the contexts of high-intensity international tourism and remote, mobile tourism systems. The visual representation of the framework further facilitates the understanding of complex relationships and is one of the strong points of the manuscript.

However, despite its clearly expressed qualities, the manuscript requires some improvements in order to reach its full potential. First of all, the methodological part is partially repeated and conceptually less defined. Although it is clearly indicated that this is a conceptual work based on a narrative literature review, it is necessary to explain more precisely the criteria for the selection of sources, as well as more clearly define the role of case studies, whether they serve exclusively as illustrative examples or have an analytical function in the development of the framework itself. Currently, this section feels descriptive and could be more concise and focused.

Additionally, the theoretical contribution of the work would be stronger if it were more explicitly positioned in relation to the existing concepts of sustainable tourism, destination resilience and destination governance approaches. Although these concepts run implicitly throughout the text, a clear discussion is lacking that would show how the proposed framework fundamentally differs from existing models and how it builds upon them. This is especially important considering that the work is of a conceptual nature and that its scientific contribution is primarily valued through theoretical originality.

The case study analysis is informative and relevant, but not entirely uniform. The case of Phuket is treated in more detail, with clearer links to market restructuring and private health investment, while the analysis of Northern Australia is more focused on a descriptive account of logistical and infrastructural challenges. It is recommended either to deepen the second case or to emphasize more clearly that the asymmetry in the depth of the analysis results from their different function in the work. Otherwise, one can get the impression of uneven comparative processing.

Also, the discussion and conclusion section could highlight the limitations of the work more clearly. The lack of empirical validation, the potential limited applicability of the framework in countries with weaker institutional capacities, and the reliance on secondary sources are important points that should be explicitly mentioned. This would further strengthen the academic rigor and transparency of the work.

On a technical and stylistic level, the text is mostly clear and well written, but in some chapters there is a slight repetition of arguments, especially in the parts related to systemic pressures and development opportunities. Careful shortening and condensing of those passages is recommended. In the references, minor inconsistencies in citing individual sources are noticeable (eg "& al." instead of "et al."), which should be harmonized with the style of the journal.

The manuscript represents a significant and high-quality contribution to the literature and has clear potential for publication. With minor, but substantively important refinements in methodological clarity, theoretical positioning and standardization of case studies, the work will be additionally strengthened and fully ready for publication.

Author Response

Comment 1: Methodological refinement Response: I thank the reviewer for this suggestion. The Methods section has been tightened to remove repetition and to more clearly define the role of the narrative review and illustrative cases. The section is now more concise and focused.

Comment 2: Clarify scope and limitations Response: I have expanded the Discussion to more clearly articulate the scope and limitations of the study. The manuscript now explicitly acknowledges its conceptual nature, reliance on secondary literature, and lack of empirical testing, while outlining priority directions for future research, including equity impacts, digital health in tourism settings, and cross-sector governance models.

Comment 3: Theoretical positioning Response: I agree that explicit positioning is essential for a conceptual paper. The revised Discussion now directly situates the framework within debates on sustainable tourism, destination resilience, and governance, and explains how the co-evolutionary perspective extends existing approaches by integrating healthcare systems as foundational destination infrastructure.

Comment 4: Reduce repetition and strengthen discussion Response: Repetition across sections has been systematically removed. Descriptive material is now confined to the framework and case sections, while the Discussion focuses on interpretation, theoretical implications, and governance relevance. This sharpening strengthens the analytical contribution and avoids restating earlier sections.

Comment 5: Case balance and limitations Response: I have clarified that differences in the depth of case discussion reflect structural differences between tourism systems, rather than uneven analytical treatment. Additionally, I have expanded the Conclusion to explicitly acknowledge limitations, including the lack of empirical validation, reliance on secondary sources, and potential constraints in low-capacity governance settings.

Comment 6: Governance implications Response: Governance implications have been clarified and consolidated into a dedicated subsection. The revised manuscript explicitly demonstrates how governance capacity mediates tourism–health interactions and determines whether tourism pressure undermines or strengthens healthcare system resilience. This responds directly to the reviewer’s request for clearer applied relevance.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting the revised version of your manuscript. After reviewing the revised text and your responses to the reviewers’ comments, I find that the paper has been substantially improved. The revisions clearly address the key concerns raised during the review process and result in noticeable improvements in structure, conceptual clarity, and analytical rigor.

In its current form, the manuscript meets the scholarly standards of the journal and represents a solid contribution to the field. I therefore support its acceptance for publication.

Kind regards,

Reviewer 2 Report

Comments and Suggestions for Authors

This paper is my second time to review.

As given, the revised version has made the improvement. I have checked my suggested points, which I reviewed at last time, all the points have well revised.

Only one thing is the Figure 1 is not clearly. That is not good quality for international readers. I think that the joural editor needs to check before publish.

Finally, this revised version is suitable for considered for the journal. 

Reviewer 3 Report

Comments and Suggestions for Authors

Authors revised manuscript