1. Introduction

Today, medical tourism is considered to be a lucrative industry, and is highly regarded by both developed and developing countries (Fetscherin & Stephano, 2016). During the years in which the medical tourism industry has been flourishing, many scholars and experts have studied and commented on it. Thinkers have presented different definitions of medical tourism based on their own points of view. All of these definitions are consistent on one point, that medical tourism is aimed at facilitating patients to benefit from better treatment facilities that are not available in their country of origin. The existence of limitations, such as lack of appropriate infrastructure, new technology, and high costs are important motives behind medical travel flows (Singh, 2019). Given the history of the industrialization of medical tourism and its ups and downs, various issues, including cultural differences, have been identified as influential factors driving the industry. Geography and the image of the destination country are also important. In addition to these factors, medical tourism does not only shape how tourism and treatment impact each other, but also has a significant influence on other international issues, including the power of nations (Aydin & Karamehmet, 2017).

Countries active in the field of medical tourism now regard this industry not only as a source of income and economic gain, but also as an ever-growing tool of power in other fields, including international relations and the world of politics (Hassan & Hemdi, 2016). Medical tourism begins as the movement of humans through their native geography and entrance to the new and unfamiliar cultural world of other nations (Aydin & Karamehmet, 2017). This flow of people not only addresses therapeutic and touristic needs but also serves as a crossroads between different cultures, an opportunity to increase soft power (Connell, 2013). The present study seeks to validate medical tourism as an opportunity for Iran.

Following the definition of medical tourism and its main aspects, a glance at the history of medical tourism in Iran and the tourist connection between the Islamic Republic of Iran and the Republic of Azerbaijan is necessary. The focus of the current research is to investigate new economic and political opportunities for the two nations by identifying and comparing medical tourism aspects. In international relations, countries communicate with each other through different lenses, including cultural, economic, political, scientific and social relations. But there are some cross-cutting issues that can serve as good platforms for bringing these communications together (Beladi, Chao, Ee, & Hollas, 2019). In other words, the difference between purely economic relations and comprehensive relations is the context in which the relations are formed between countries.

One of the platforms for comprehensive relations between two countries is medical tourism. As stated earlier, medical tourism encompasses a variety of dimensions, each with specific benefits depending on the circumstances (Labonté, Crooks, Valdés, Runnels, & Snyder, 2018). Iran and Azerbaijan, in addition to sharing geographical borders, also have religious, ethnic and linguistic commonalities, which facilitate communication between the people of these two countries (Souleimanov & Ditrych, 2007). The people of Iran and Azerbaijan have both regularly hosted foreign tourists for various reasons over the past years, but the tourism connection between the two countries in particular has deeper roots. The solidarity between the people of northwestern Iran and the people of Azerbaijan dates back to the years before the independence of the Republic of Azerbaijan. Given this deep ethnic and linguistic solidarity, the tourism relationship between the two countries in recent years, especially after 2015, has taken on a new identity (Khalili, 2015), which will be examined in the continuation of this article.

1.1. Study Questions

Iran has strengths and weaknesses in the field of medical tourism, which can be further improved by removing barriers and taking effective steps to strengthen the economic structure (Jabbari, Delgoshaei, Mardani, & Tabibi, 2012). This article addresses the following questions:

-  What are the factors driving medical tourism?

-  How do the factors driving medical tourism lead us to identify new economic and political opportunities regarding Azerbaijani medical tourists?

-  What are possible strategies to attract more Azerbaijani medical tourists based on the considerations identified?

2. Medical Tourism as an Industry

Industry in the general sense means the application of human creativity to natural resources and their preparation for human use. In the past, wealth was often seen as something fixed, and man was not considered to have the talent to create wealth, but in modern times, contrary to the past, much of society's wealth is the product of human labor and industry. So industry means using human creativity to create goods and transforming natural resources to meet human needs (McLean, 2007). Accordingly, medical tourism has come a long way to become what it is today, the medical tourism industry.

From ancient times, people have been travelling to other places to access medical treatments and services, the main reason for these travels being limitations in patients’ own area of residence. Before the emergence of complex technologies in the field of medical tourism, people who wanted better healthcare outcomes traveled to mineral thermal springs and baths (Ile & Țigu, 2017). As George Weisz (2011) notes, mineral waters were connected to place and such baths and their therapeutic powers were intimately connected to their sacred location. In the Greek Empire, important healing temples attracted people from across the world (Katsoni et al., 2016). The most famous temples were Asclepia, constructed in honor of the god of medicine Asclepius, the sanctuary of Zeus in Olympia and the temple of Delphi (Li & Cui, 2014). These temples delivered enormous economic benefits to their cities. In fact, every city that had hot springs was famous (Derco & Pavlisinova, 2017).

The use of mineral water for treatment still took place in the nineteenth century, but gradually the correlation between religion and medicine became weaker and economic interests and health services were recognized as the two main levers controlling medical tourism (Turner, 2007). Li and Cui (2014) state that in France, an entire academic discipline on ‘medicalized thermalism’ was established to promote the spa industry by adorning it with a “scientific” appearance. This process led to significant economic revenue from spa waters, and spas were counted among the most important touristic destinations. However, in the late nineteenth century, spas lost their reputation due to the expansion of scientific studies in the field of medical services (Weisz, 2011).

By the middle of the twentieth century, medical tourism was still interpreted as travel to access medical services not available domestically. Medical tourism has grown substantially since the 1990s, driven by the movement of thousands of patients from all over the world to specific countries for medical services (Moghimehfar & Nasr-Esfahani, 2011). In the 1980s and 90s, Latin American countries welcomed foreign medical tourists for the first time (Ormond & Sulianti, 2017). In the course of 1990s, many medical tourism facilitating companies formed. The growth of medical tourism has been accompanied by the dramatic growth of medical travel companies. The twentieth century witnessed the expansion of medical tourism from North America to Europe and Asia (Sobo, Herlihy, & Bicker, 2011).

In the twenty-first century, medical tourism has grown significantly. This growth can be seen in both the value of investment in the industry and the number of medical tourists. In 2016, the global value of the medical tourism industry was estimated at 439 billion USD (Inhorn & Patrizio, 2015). Since the beginning of the twenty-first century, countries such as India, Thailand, Malaysia, Turkey and Brazil have been the most important destinations for medical tourism. These countries invest heavily in the medical tourism sector (Mainil, 2012). In 2012, for example, the value of medical tourism in India was 1 billion USD (Ajmera, 2017), and in 2018, the Turkish Ministry of Health reported that Turkey had earned 1.5 billion USDfrom medical tourism that year (Sag & Zengul, 2019).

In 2018, the annual number of medical tourists globally was estimated at 11 million. The increasing trend is reflected in individual country statistics. For example, the number of tourists traveling to Malaysia rose from 600,000 in 2011 to 1.2 million in 2018 (Ormond & Sulianti, 2017). The number of medical tourists has grown significantly since the beginning of the twenty-first century for two reasons. First, the middle class has grown exponentially in developing countries, which means that more people have become acquainted with new opportunities and are more aware of the medical services provided in other countries. Second, international travel is easier and more affordable due to the expansion of infrastructure and facilities (Béland & Zarzeczny, 2018).

2.1. The Concept of Medical Tourism

Various criteria can be considered in a definition of medical tourism. Based on the definitions of experts like Sandberg (2017), medical tourism is international travel with the aim of benefiting from medical services. This kind of definition describes medical tourism as organized travel outside of one's living environment to improve one’s physical and mental status (Carrera & Bridges, 2006; Sandberg, 2017). Cormany and Baloglu (2011) define medical tourism as the act of travelling abroad for medical treatment. Connell (2006) also describes medical tourism as international travel which is linked to direct medical intervention.

In addition to what has been emphasized (travel to obtain medical care), specific motivations for travel are also important. The variety of patients’ motives for traveling to distant locations can help to clarify the concept of medical tourism. Incentives like low cost, short wait times and availability of services encourage medical tourists to travel to a specific destination (Hopkins, Labonté, Runnels & Packer, 2010). From another point of view, medical tourism is considered a valuable niche, which increases price competition among destination countries (Connell, 2016). Depending on the intention and need of patients, different terms can be used to convey the concept accurately. There are three main terms: medical tourism, wellness tourism and health tourism (Aydin & Karamehmet, 2017). The reason for this multiplicity is the lack of clear boundaries between these terms.

The World Tourism Organization (UNWTO) has defined health tourism as the supply of health facilities beyond national borders  (World Tourism Organization & European Travel Commission, 2018). Some other researchers believe that health tourism is composed of wellness tourism and medical tourism (Cesario, 2018; Smith and Puczko, 2014). Smith & Puczko (2014) also add that because it is about surgery, medical tourism is the correct term. But in contrary to Smith and Puczkó’s (2014) claim, Connell (2016) believes that medical tourism is an inappropriate term because someone who travels for medical treatment is not a tourist. The other term, wellness tourism, is defined by Global Wellness Tourism Economy (GWTE) not only as receiving medical services but also gaining peace of mind (Smith & Kelly, 2006).

2.2. Factors Driving Medical Tourism

The analysis of the many dimensions of medical tourism facilitates a more detailed depiction of the industry. Relevant factors driving medical tourism include culture, quality, infrastructure and technology, cost, transportation, and the political situation of destination countries (Nicolaides & Grobler, 2017).

2.2.1. Quality and Culture

In this study, aspects of medical tourism have been examined separately insofar as this was possible. However, the two factors of culture and quality were studied together due to the inseparable relationship between them.

Quality is defined as addressing the needs and demands of customers (Wu & Li, 2016). This involves not only meeting customers’ needs but also exceeding their expectations and competing with other competitors on the market to be known as a good service provider (Junio, Kim & Lee, 2017). The basic definition for quality is fitness for use (Aziz, Yusof, Ayob & Bakar 2015). For this reason, researchers consider customer satisfaction the most important sign of quality (Wu & Li, 2016). The quality of products and services must have certain characteristics and features in order to satisfy the different needs of customers (Aziz et al., 2015). The precise identification of obvious and hidden preferences, needs and desires of customers and their implementation leads to customer satisfaction and loyalty (Aziz
et al., 2015). Customers’ experiences, which are expressed in the form of positive or negative feedback, has a tremendous effect on service providers. The service experience is defined as customers’ personal reaction and feeling while using the services and the level of satisfaction they have gained (Babakus & Mangold, 1992).

As mentioned, paying attention to all the needs of patients leads to increased quality. One of these needs is appropriate communication between the host and the patient in the context of a common language. Having a common language in all stages of a foreign trip, from hotel accommodation to the patient's communication with their doctor, is one of the important factors in improving the quality of medical tourism (Liu & Chen, 2013). This is where the connection between quality and culture comes into play.

To understand the effect of culture in medical tourism, one’s familiarity with cultural diversity is essential. In summary, it can be said that a group of people in a geographic region, based on the living conditions, create certain traditions, beliefs and values (Esiyok, Çakar & Kurtulmuşoğlu, 2017). In other words, differences in ethnicity, nationality, religion, language, and social habits lead to diversity in culture (Betancourt, Green, & Carrillo, 2005). Investigating the cultural aspects of medical tourism can be considered a two-way issue. The destination country must be aware of the language, beliefs and values of the patients, and the tourists must have sufficient information about the culture and customs of the destination country (Connell, 2013).

Culture has been emphasized as being an important factor in shaping patterns of medical tourism (Glinos, Baeten, Helble & Maarse, 2010; Jagyasi, 2010; Liu & Chen, 2013). As many writers, including Connell (2016) point out, the destination country should be attractive to patients and tourists. Cultural similarities can be considered as an attraction for tourists (John & Larke, 2016). Some researchers have suggested that cultural similarities have a great impact on the destination selection process. Yu and Ko (2012) report significant cross-cultural perceptual differences between Chinese, Japanese, and Korean medical tourists in terms of selection of destination. Another study which has confirmed the impact of culture on medical tourism addresses cultural affinity as a factor in the selection of Iran as a destination country (Goodarzi, Taghvaei, & Zangiabadi. 2014). Cultural similarities could also motivate diaspora patients to go to their motherland to use medical treatments (Esiyok et al., 2017).

According to Heung, Kucukusta, and Song (2011), in medical tourism, cultural aspects are always examined alongside geographical aspects. The authors believe that culture, like geography, has borders and the greater distance away, the lesser possibility of effective communication. Culture can be divided into factors such as language, religion, and cultural commonality (Jovicic, 2016; Liu & Chen, 2013). In order to make the culture factor more meaningful and understand the special advantages for Iran in attracting Azeri tourists, a brief review is necessary:

a) Religion: According to the Global Religious Future website, more than 96 percent of the population of Azerbaijan are Muslim, and most are Shiite, and this has led to a deep cultural commonality with Iran (Valiyev, 2005).

b) Art: Art, which includes the various aspects of music, theater, media, literature and other expressions, can be a very influential factor in bilateral relations. For example, prominent Iranian films are shown in Azerbaijan. In the field of media, Iran has supported the publication of the “Voice of Islam” newspaper in Azerbaijan, and its “Sahar” television channel in the Azeri language has attracted the attention of the Azerbaijani people. One of the cultural commonalities of the people of the two countries is art and theater: Iranian and Azerbaijani artists frequently collaborate with each other. One of the strongest reasons for cultural connection is ethnic and linguistic commonality (Oldfield & Nikaeen, 2018).

c) Customs: Another cultural commonality between the two countries is the celebration of various holidays and ceremonies, including the ancient holiday of Nowruz, which is commemorated in both Iran and Azerbaijan with special customs and ceremonies (Koolaee & Hafezian, 2010).

d) Azeri ethnicity and language: Iran is a multi-ethnic community and the second largest ethnic and racial group are the Azeris, who make up about a third of Iran's population. Azeri language and ethnicity are another common denominator between Azerbaijan and the people of northwestern Iran. This feature can be a strong factor for cooperation (Khalili, 2015).

The rise of international communications has led to some concerns for international organizations and institutions. One area of these relates to issues arising from differences in languages between people across the world (Tsui & Tollefson, 2017). Language is the first and most important tool of communication. Problems caused by differences in language and their resolution are discussed in relation to the medical tourism industry. If the patient fails to communicate with the doctor treating them, there will be no trust (John & Larke, 2016; Holmqvist, 2009). Jansson (2014) highlights that there is a pressing need for research addressing the linguistic complexities of health care interactions.

Holmqvist and Grönroos (2012) point out that because of language differences, some destinations focus on indirect communication, such as via branding, advertising, written messages and other one-way communication channels. Morales, Cunningham, Brown, Liu, & Hays, (1999) mention that optimal treatment outcomes are strongly dependent on satisfactory communication between patients and physicians in relation to medical test results, medications and treatment options. Linguistic concerns can be solved by medical tourists in two ways: the first is to learn the language of the destination country and the second is to travel to a country with linguistic similarities to one’s own (Momeni, Janati, Imani & Khodayari-Zarnaq, 2018). It can be concluded that religion and language, which is shared in the form of culture (Connell, 2006), are among the most important factors attracting Azeri medical tourists to Iran.

In addition to cultural commonalities that enhance quality, the quality of health care is also an important factor. In the healthcare arena, perceived quality of service is based on patients’ judgment (Hall, Martin, Ramamonjiarivelo & Martin, 2011). In the case of medical tourism, patients from different countries with different cultures are customers of the services provided, but they do not all see quality in the same way, because expectations and individual experiences are not identical (Wang, 2012).

Despite the fact that quality arises from the tastes and experiences of patients, it also has an external appearance (Loureiro, 2017). Providing appropriate services using up-to-date technology and establishing effective communication between service providers and patients is associated with patient satisfaction and trust in the medical procedure (Connell, 2016). Quality transcends all aspects of the medical tourism experience (Chuang, Liu, Lu & Lee, 2014). Quality is involved in all of the components of medical tourism, because when a patient is in an unfamiliar environment, any unforeseen factor can challenge their perception of quality (Han & Hyun, 2015). In general, quality means meeting the standards of healthcare provision (Guiry & Vequist, 2011).

2.2.2. Infrastructure

One of the important and significant factors affected medical tourism is the availability of appropriate infrastructure to serve medical tourists (Sandberg, 2017). The construction of infrastructure and the increase of the annual number of accepted medical tourists are two related issues, which can be achieved over time and with precise urban development plans (Connell, 2016). There is a major difference between the infrastructure aspect and other aspects of medical tourism, and infrastructure is a particularly wide-ranging issue (Lunt, Horsfall & Hanefeld, 2016). Infrastructure is best explained by separating it into three distinct branches. The first comprises accommodation facilities like hotels, hospitals and urban transportation systems. The second is the deployment of medical and care (i.e. nursing) professionals in hospitals and clinics. The third is the use of new tools and technologies in medical tourism (Junio, Kim & Lee, 2017; Connell, 2013).

In explaining the first branch, it should be noted that most of the hospitals which host medical tourists in destination countries are built and operated by the private sector, and their relationship with other facilities, whether governmental or private, is not always uniform (Omay & Cengiz, 2013). The infrastructure of the medical tourism industry should be in direct coordination between all services so as to create a relaxed and suitable environment for patients (Connell, 2011). Here it is imperative that, in addition to buildings and other facilities, the people of the destination country are psychologically prepared for the presence of medical tourists. Otherwise, regardless of facilities, medical tourism in that country will not grow (Tham, 2018).

In relation to the second branch, the existence of well-trained medical and nursing specialists in the field of medical tourism has two major benefits. Firstly, it increases the trust of patients around the world towards the health care providers, and secondly, the presence of well-known doctors attracts more patients (Moghavvemi et al., 2017).

Due to general interest in the use of new and effective technologies, the third component has an effective role in attracting medical tourists. Offering new methods for patients in order to benefit from faster and more reliable treatments is considered one of the basic benefits of new medical technology (Abadi, Sahebi, Arab, Alavi & Karachi, 2018). For example, dentistry is one of the areas in which new technologies, such as implants and laminates have been introduced, and in advanced countries these technologies are very expensive (Moghavvemi et al., 2017). Thus, the existence of medical infrastructure, including technology and specialized physicians, has huge potential in the medical tourism industry, especially in developing countries where prices are relatively less expensive.

2.2.3. Destination Image

One of the most important concepts in medical tourism is the image of destination country (Junio et al., 2017). The destination image has been defined as the mental perception held by travelers or the whole set of imaginations about a particular destination (Jalilvand & Samiei, 2012). It is also an attitudinal notion relating to the plurality of ideas, impressions, and feelings that a traveler holds about a destination (Li & Wang, 2010). Destination image is the effectiveness of the characteristics of a destination country in the medical tourism destination selection process (Dryglas & Salamaga, 2017). From the perspective of tourists, the image of the destination is interpreted based on considerations such as travel schedule, cultural background, the purpose of the visit, educational level, and past travel experiences (Mohamad, Abdullah & Mokhlis, 2012).

These definitions show that the image of the destination is an important factor for tourists and can lead to successful decision-making (Khan, Chelliah & Haron, 2016). In other words, having a specific image of a destination country in mind increases the possibility of the selection of an appropriate destination. Tourists’ perceptions of destinations’ attributes have been generated through some means of information provision (Tasci, Gartner & Cavusgil, 2007). Therefore, the destination image should be promoted in order to increase medical tourists’ awareness by informing them of the advantages of the destination country.

According to Chon (1990) & Dryglas and Salamaga (2017), a destination image is a perception reflected in customers’ memories. According to other researchers (Clemes, Gan & Ren, 2011; Tham, Croy and Mair, 2013), image is measured by the prestige of the destination country in competition with other possible destinations. Hall, James and Baird (2011) have defined tourism attractions as specific features of a destination such as climate, landscape features, and activities at the destination. In research by Kumar and Hussian (2016) alongside Hu and Ritchie (1993) five attributes relating to the attractiveness of tourism destination are introduced. These include geographical factors, socio-cultural factors, natural attributes, physical attributes and political values.

In a different model, the image of a destination is identified by factors such as quality, price, value, and satisfaction (Khan et al., 2016; Tasci et al., 2007). In a medical tourism context, if healthcare providers want to attract medical tourists to visit a country, they need to build a good image and promote it through their medical health care facilities (Connell, 2016). A good image of medical care could be developed through advancing technology and equipment, meeting high levels of international standards in the field of health care, and employing well-trained medical experts (Tasci et al., 2007). In so doing, medical tourists would consider the provider favorably as their present as well as possible future destination. This means that medical tourism providers must be ready for medical tourists or travelers in terms of the quality of their treatment, health care, and hospitality facilities (Chomvilailuk & Srisomyong, 2015).

In this regard, one of the important factors in presenting a destination image is the political situation of the destination country. Political situation means that the destination is away from any insecurity, whether foreign or domestic, demonstrations and international threats. Destinations should be able to guarantee the comfort and safety of the tourists in order to be on the list of medical tourism destinations (Johnston, Crooks, Snyder & Kingsbury, 2015; Connell, 2016).

Based on what was said about the destination image factor, the views of the Azerbaijani people towards Iran are considered. How Azerbaijani people view Iran depends on a set of factors, but it is clear that the image of Iran in the minds of the Azerbaijani people plays a key role in choosing Iran as the destination country. Part of the knowledge of the Azerbaijani people about Iran is due to their common language, religion and ethnicity, which makes it easier to gain knowledge about Iran. The people of Azerbaijan consider the people of the northern provinces of Iran as their brothers and relatives and feel very close to them. But on the other hand, the differences in the political values of the two countries, the Islamic Republic of Iran and the Republic of Azerbaijan, pose serious challenges to the solidarity of the two countries (Nassibli, 1999). However, in relation to medical tourism, Iran, in addition to its cultural attractions and commonalities, has suitable infrastructure and conditions, which means it has a positive image in the minds of Azerbaijani tourists.

2.2.4. Cost

Medical tourism experiences growth due to the reasons such as the high cost and unavailability of healthcare domestically (Barrowman, Grubor & Chandu, 2010; Junio et al., 2017). A number of different factors encourage patients to travel to other countries in order to use medical services. These factors can be divided into two main categories of push factors or the demand side, and pull factors or the supply side (Khan et al. 2017).

Each of these categories is multidimensional but the focus of the medical tourism process on cost is very significant (Connell, 2016). Push factors include high financial and time costs, the unavailability of health services, and low levels of technology in one’s own country. In contrast, pull factors include low cost, always attractive for patients (Crompton, 1992). Cost considerations can be divided into two parts, time cost and financial cost (John & Larke, 2016). One of the reasons that patients travel from developed countries to developing countries is the long waiting list for health care (Connell, 2013). In countries such as the England, waiting times can reach six months or more (Bookman & Bookman, 2007). For a patient, time can be worth more than a certain price, and the waste of time can be considered an expense (Milstein & Smith, 2006). Financial costs can also be categorized into three parts comprising transportation costs, health care costs, and the costs of using the country's facilities including hotels, tourist areas and food (Skountridaki, 2017).

The cost of touristic facilities depends on the growth of the destination country in the field of tourism (Connell, 2006). Transportation is closely related to the geographical aspects of a potential medical tourism destination (Esiyok et al., 2017). Usually, the three factors of cost, culture and geographical proximity are examined together (Junio et al., 2017). Geographical proximity has two main aspects, first, medical travel is regional not global because of the time taken to travel, second, it is easier to enter neighboring countries because visa issuance arrangements are usually favorable (Williams, 2016). The three aforementioned factors will be examined in combination here.

As stated, geography determines two important things. The first is the sum of transportation costs, whereby greater distance between the origin and destination countries results in greater overall cost (Williams, 2016). The second is cultural and linguistic proximity between the countries in a region (Esiyok et al. 2017). For example, Southeast Asian countries are the first destinations selected by Arab patients. In another example, people of Afghanistan, Azerbaijan and Iraq tend to travel for medical reasons to destinations like Iran and Turkey because of the lower cost of transportation and cultural/linguistic similarities (Momeni et al., 2018).

An important part of the health care costs in the destination country is medical care. Hospital services, surgical operations, plastic surgeries, dentistry, organ transplantation and the nursing of patients are the most common costs for medical tourists (Connell, 2013). These health care services are offered in developed countries, usually at a fraction of the price. Countries such as the United States, England and Germany charge nearly ten times more than what is expected in developing countries (Connell, 2016).

3. Medical Tourism in Iran

Many articles have been written about the current state of medical tourism in Iran. Among these, those analyzed in this study were first published after 2012, and present a range of significantly different conclusions. The reason for considering these two components in article selection was to analyze opposing views, avoid repetition and maintain currency.

A common thread throughout most of these articles comprised discussions of the challenges and obstacles facing medical tourism in Iran. In an article titled “Training Medical Tourism in Iran,” Danial, Abbaspour, Rahimian, Shaarbafchi Zadeh, & Niknami (2017) address the challenges facing Iran and mention that the most important of them is a lack of trained medical staff in the field of medical tourism. Danial et al. believe that training is necessary not only in the field of medical services but also in the field of foreign languages and appropriate communication with patients. The level of education that Danial et al. (2017) consider necessary is based on international standards, which indicates their perception that Iran has low educational standards. The authors claim that private sector investment in the medical tourism industry is one of the key factors in developing medical tourism. One of the potential capacities that Danial et al. (2017) mention in this article is religious commonalities, which can attract Muslim tourists from other Islamic countries.

Jabbari et al. (2012) also point to the challenges facing Iran in developing its medical tourism industry. Unlike Danial et al. (2017), Jabbari et al. believe that one of Iran's key capacities is its specialized and trained personnel in the field of medical tourism. One of the reasons for this sharp disagreement over the issue of training is a lack of accurate information and statistics on the number and manner of training of specialists active in the field of medical tourism (Tabibi, Nasiripour, Ayubian & Bagherian, 2012). Jabbari et al. (2012) go on to cite capacities such as quality infrastructure, natural attractions and Iran’s rich history as factors attracting medical tourists.

In an article entitled “Situation of Health Tourism in Iran: Opportunity or Threat,” Izadi et al. (2012) point to the weakness of resource management and considers the governmental nature of the medical tourism industry as a reason for its backwardness. Unlike Jabbari et al. (2012), Izadi et al. (2012) believe that Iran’s medical tourism infrastructure is inadequate. The reason for the disagreement about the existence of appropriate infrastructure is due to variation between different cities in Iran. For example, in articles where Iran's major cities, such as Tehran, Tabriz and Shiraz are considered tourist destinations, the existence of infrastructure is acknowledged. But if the research take places in the context of small and border towns, the opposite is true. Izadi et al. (2012) go on to point out the low cost of treatment in Iran and considers this an attractive feature for foreign tourists. Like Danial et al. (2017), Izadi et al. (2012) point to the lack of skilled labor in Iran.

A further relevant article addresses the challenges facing Iran’s East Azerbaijan province (one of the northwestern provinces of Iran which borders the Republic of Azerbaijan) in the development of medical tourism. In this article, Momeni et al. (2018) criticize the way resources are managed and the government's lack of attention to the lucrative medical tourism industry. The authors believe that Iran's dependence on oil prevents the government from paying attention to this industry and does not take appropriate steps to improve it. Like Izadi et al. (2012), Momeni and colleagues believe that the cost of treatment in Iran is much lower than in other countries in the region, and that this could be a good reason for Iran to participate in the competitive medical tourism market. Momeni et al. (2018) also consider the existence of appropriate infrastructure and religious and linguistic commonalities with its northern neighbor as factors that attract medical tourists.

4. Methodology

The purpose of this article is to examine the attractiveness of Iran as a medical tourism destination for the people of Azerbaijan, and the opportunities Iran could leverage in this arena. The general course of this research is as follows:

1. Review of related articles and books in order to identify factors affecting medical tourism

2. Distribution of questionnaires among experts to rank factors

3. Review and analysis of the answers given and design of a prioritization table

After identifying the factors affecting medical tourism considered in many articles in the field of medical tourism, they were investigated using the Analytic Hierarchy Process (AHP) method. The AHP method is a multi-criteria decision-making method (Saaty, 2004), which is completed using the Expert Choice software package. In this research, the questionnaire responses provided by experts in medical tourism were transferred into the software. The criteria and sub-criteria from the questionnaire were compared in binary form, and the software produced a hierarchy of criteria (see Figure 1).

Figure 1. Hierarchy of Criteria (produced based on the factors extracted from the article review)

One of the important steps in the AHP approach is to collect expert opinions. In this method, a hierarchy of criteria was established in the first instance. The questionnaire developed for this study was divided into two main components: the comparison of the criteria to the main goal; and the comparison of the sub-criteria to the relative criteria. The reason for using the term criterion instead of variable is to comply with the research method. In this method, criteria are assumed to be fixed concepts that are compared with each other.

Table 1. Scale for Making Judgements
Source: Based on Satty (2004)

According to the number of questionnaires required by the AHP method, in this research, ten questionnaires were distributed among health tourism specialists. The respondents were aged between 48 and 63 years old, and they comprised seven men and three women. Each expert was a specialist in a different discipline, each of which was relevant to the topic of medical tourism. Two of the respondents were tourism experts with more than 15 years of research experience in the field. Four respondents were physicians with more than 20 years of experience and practice included a university professor from Tabriz University of Medical Sciences, a hospital treatment assistant from Urmia Omid Hospital and Tabriz International Hospital, a head of a hospital in Urmia and a physician with experience conducting treatment in the Republic of Azerbaijan. Four other professionals, with more than 10 years of experience in various fields of study, comprising sociology, hotel management, medical engineering, and religious sciences in the field of medical tourism, also participated. The information obtained from the questionnaires was analyzed by Expert Choice software.

In addition to the questionnaire, short interviews were conducted with eight Azerbaijani patients who were present in Ardabil (one of the northern cities of Iran, which shares geographical borders with the Republic of Azerbaijan and the people speak in Azeri). The interviewees were aged from 25 to 63 years old. Five patients had university degrees and government jobs. Of the eight interviewees, five were male and three were female. The main interview questions were as follows:

a) Why did you travel to Iran?

b) Why did you choose Iranian medical services instead of those provided in countries like Turkey and Russia?

c) How much money (per person) did you spend to receive medical services and stay in Iran?

The questionnaires responses and interviews were used as the secondary source of data and the academic journals as the primary source of data. This paper utilized a quantitative research methodology, using a multi-criteria decision-making method according to a holistic approach. The framework used for this study’s methodology is shown in Figure 2.

Figure 2. Methodology Structure

5. Results

In this article, the factors affecting peoples’ decisions to undertake medical tourism were examined. This study is important because it shows what factors are important for Azerbaijani tourists. In other words, according to what criteria do Azeri medical tourists choose Iran as a destination country? What follows are the experts’ responses to this question. Figure 3 demonstrates the position of each criterion, reflecting experts’ opinions on this issue.

Figure 3. Priority Weighting (based on Expert Choice Software)

The software also produced a ranking table (see Table 2), which indicates the rank of each criterion and its sub-criteria.

Table 2. Ranking Table of Criteria and Sub-Criteria
Based on Weight and Percentage

The evaluation and prioritization of internal factors in attracting medical tourists in Iran from the point of view of physicians, hospital managers and the owners of services related to medical tourism were investigated using the AHP method, and produced the following results:

a)    Among the five criteria i.e., quality, costs, culture, infrastructure and destination image, the quality criterion with a weight of 316 received the highest score, and the cost criterion with a weight of 277 ranked in second place.

b)   Between the two sub-criteria of quality, quality of health care services and quality of effective communication between the medical staff and the patient, the quality of health care sub-criterion gained a higher score.

c)    In this research, the cost criterion was evaluated based on four sub-criteria: cost of health care services, cost of welfare services, cost of transportation and time cost, and the cost of health care services was ranked in first place.

d)   The culture criterion included the four sub-criteria of geographical proximity, ethnic commonality, religious commonality, and linguistic commonality, and geographical proximity received the highest score.

e)    In relation to the infrastructure criterion, among the three sub-criteria of expert medical staff, technology and welfare services, expert medical staff was ranked first.

f)    Destination image was assessed on the basis of eight sub-criteria including psychological security, cultural values, political values, tourist reception capacity, tourist attractions, climate conditions, national demonstrations, and external threats, among which psychological security ranked first.

g)   The results of the total integration of the 21 sub-criteria showed that the sub-criterion of quality of health services ranked first and the two sub-criteria of tourist attractions and climate conditions ranked last.

6. Medical Tourism Guarantees Mutual Interests

The most important incentive for countries to connect with each other is to gain benefits. Medical tourism is a good platform for connection due to its various dimensions. By traveling to Iran, Azerbaijani tourists not only benefit from quality medical services but also contribute to Iran's economy. What follows are statistics on the presence of Azeri tourists in Iran between 2012 & 2019.

On February 18, 2020, the Azarnews website published a report about a tourism symposium between Iran and Azerbaijan. The ambassador of Azerbaijan to Iran acknowledged at the meeting that Iran is one of the most important tourist destinations for Azeris (Gasimova, 2020). There are also other reports which introduce Iran as the second most popular destination for Azeri tourists in 2019, one stating that these tourists spent a sum total of 308 million USD to travel to Iran (Iran Second Most Popular, 2020). More than one million Azerbaijanis traveled to Iran in 2018, a 32 percent increase from 2017. Some experts believe that the reason for this significant growth was the devaluation of Iran’s currency (IRR) and the increase in the value of Azerbaijan’s (AZN) (Over 1m Azeri Tourists, 2018).

Despite the publication of different statistics on the number of Azerbaijani tourists visiting Iran, accurate statistics on medical tourists are not yet available. On June 18, 2018, Mehr News Agency published a report that introduced Iran as the most popular destination for middle class Azeri medical tourists. According to published statistics, the number of Azeri tourists in Iran peaked in 2015–2016, in which years 50 to 60 percent of visitors were medical tourists (Iran, Azerbaijanis’ First Choice, 2018).

6.1. Iran as a Better Choice

According to the State Statistics Committee of the Republic of Azerbaijan, in 2018, 4.9 million citizens of the Republic of Azerbaijan traveled to foreign countries, 33.6 percent of whom travelled to the Islamic Republic of Iran (Hashimli, 2019). Experts believe that the reason for the increase in the number of Azerbaijani citizens traveling to Iran is the increase in the purchasing power of the AZN. Meanwhile, statistics reported by the State Statistics Committee of the Republic of Azerbaijan also show that in 2018, 29.2 percent of the citizens of the Republic of Azerbaijan who travelled internationally went to Georgia, 18.9 percent to Russia, 12.3 percent to Turkey, 1.4 percent to Ukraine, 9.0 percent to the UAE and 3.7 percent to other countries (Hashimli, 2019).

In 2018, Fouladi et al. published an article entitled “Factors Affecting Medical Trip from the Perspective of Azerbaijani Tourists, Iran 2016.” Through interviews with Azerbaijani tourists, Fouladi and colleagues (2018) sought the reason for their presence in Iran. The results of this article show that more than 62 percent of Azeri tourists traveled to Iran to receive medical services. Among the factors that attracted them, the two factors of quality of medical services and low cost played the most important roles.

One of the most important parts of Fouladi et al.’s (2018) article is the introduction of Iran as a suitable destination for medical tourism in the eyes of the Azerbaijani people. Based on this, it was decided to conduct the short interviews with eight Azerbaijani tourists in Ardabil to find out the reasons why they traveled to Iran. The interviewees’ answers reveals further information about this matter.

The interviewees mentioned three main points in explaining the reasons for traveling to Iran compared to countries such as Turkey and Russia. According to all interviewees, geographical and cultural proximity to the people of northern and northwestern Iran were the two main factors in their selection. They considered geographical proximity not only a factor in terms of cheapness and ease of travel, but also claimed that they have more ethnic and linguistic commonalities with the Iranian people compared to the Turkish people. The interviewees stated that they did not have a good experience of traveling to countries like Russia. In addition, the people of Azerbaijan, according to the interviewees’ perspectives, have more trust in the Iranian medical system.

Three main factors could be identified in the responses received:

a) Lack of trust in Azeri doctors: According to most of the interviewees, Azeri doctors do not have sufficient knowledge and skills and being treated by them is a big risk. On the contrary, the interviewees had a lot of trust in Iranian doctors and believed that Iranian doctors are literate and skilled.

b) Cheap medical services: Five of the interviewees said that cheap medical services were the second most important reason for their travel to Iran. According to one of the interviewees, the medical system of Azerbaijan not only has major problems but is also staggeringly costly. The medical services in Iran, in addition to their high quality, are also priced less expensively. Two others also mentioned geographical proximity as a factor in the cheapness of travel to Iran. According to the experience of the interviewees, on average, every Azeri person who travels to Iran to receive medical services spends 3,000 AZN (about 1750 USD).

c) Linguistic commonalities: Four of the interviewees considered linguistic commonalities between the people of Azerbaijan and the people of northwestern Iran as one of the important factors in their selection to travel to Iran.

Based on the answers received, which, of course, were expressed with some conservatism and fear of the government of the Republic of Azerbaijan, it can be concluded that medical services in Iran occupy a special place in the minds of middle class Azerbaijani people.

6.2. Iran's Opportunities

Based on the results obtained, it is important to note that what makes Iran an attractive destination for Azerbaijani medical tourists is mainly quality and cost. On the other hand, cultural commonality and geographical proximity, in addition to managing price and quality, can also play an important role in attracting more Azeri medical tourists.

Tourists from the Republic of Azerbaijan, and especially those who travel to Iran for medical treatment, represent an opportunity for the Iranian economy, which, with proper planning, can be used to strengthen economic structure. Since tourism is a service industry and relies on human resources, its prospering can reduce the problem of unemployment, especially the unemployment of educated youth, and give new life to private sector activities (Maryam Gholami, Keshtvarz Hesam Abadi, Milady & Gholami, 2020).

Several decision-making authorities are involved in providing tourism services that contribute to medical tourism. The public sector is mostly responsible for the ownership and management of infrastructure, non-profit organizations are responsible for overseeing tourist attractions, and the private sector is responsible for providing services to tourists (Gholami et al., 2020). If these departments were more coordinated, it would be possible for medical tourism to be more organized in a way that created sustainable jobs, especially for the educated youth of the country. Experts believe that in order to promote medical tourism between Iran and the Republic of Azerbaijan, coordination efforts should include the creation of a specific database, and the provision of services from airport to airport or from terminal to terminal by licensed and designated travel agencies. Appropriate tariffs should also be determined for such services.

In addition to economic opportunities, Iran can increase its cultural and social ties with the people of the Republic of Azerbaijan and acquaint them with its political and cultural values. Opportunities include:

Scientific opportunities: improving the educational level of universities in order to coordinate with the medical tourism industry, creating new academic disciplines in line with the principles of medical tourism development.

Political opportunities: increasing the familiarity of Azeri tourists with the political and cultural values ​​of Iran, improving the level of interaction between the people of the two countries in line with foreign policy. In other words, medical tourism can be seen as an opportunity to promote Iran's soft power. According to Joseph Nye Jnr (2014), cultural values ​​and foreign policy are sources of soft power.

Economic opportunities: increasing national income and foreign exchange inflow into the country, more entrepreneurial opportunities, attracting domestic and foreign capital, promoting tourist attractions, expanding medical infrastructure not only for tourists but also for Iranian residents. The presence of Azeri tourists in the northern provinces of Iran not only generates income in the medical sector, but also supports the hotel and urban transportation industries. Since the cost of food in Iran is much cheaper than in the Republic of Azerbaijan, attracting more tourists can revive small services such as restaurants.

6.3. Impact of Currency Fluctuations on Medical Tourism Industry in Iran

Currency fluctuations have a multifaceted effect on medical tourism. The fall in the value of the IRR against the USD has created a situation where the cost of treatment and accommodation in Iran is very cheap for many medical tourists, especially Azerbaijani tourists. In fact, this is a point that can turn threats into opportunities and make Iran an important hub for medical tourism in the region (Mohammadi Khyareh, 2017).

According to Boroumand, Mohammadi, Pajooyan, and Memarnejad (2019), Iran's current capacity can cover medical services for up to one million Azeri patients per year. Comparing Iran's medical tourism industry with that of neighboring countries, the authors explain that Turkey has invested well in this area and achieved great success. Iran's health services are at least equal to or even better than this country, but Turkey has been able to overtake Iran in terms of planning. In this situation, due to the depreciation of the IRR against the USD, it can be predicted that if supported by scientific and coherent planning, Iran's medical tourism industry will surpass rival countries in the region such as Turkey and even India (Boroumand et al., 2019).

Shahbazi (2019) also believe that the devaluation of the national currency, if accompanied by adequate planning, could revive the tourism industry. The authors stress that governments in Iran view the devaluation of the national currency negatively, While countries such as China and Turkey, contrary to the opinion of Iranian officials, have leveraged their relatively weak currencies to boost their tourism industries and improve their exports, which Iran has not done as well (Shahbazi, 2019).

It should not be forgotten that the devaluation of the national currency only works to develop exports, attract tourists and reduce the unemployment rate if precise scientific goals and expert strategies are adopted. In Iran, according to international standards, 2,400 USD is generated by each medical tourist, indicating that this sector can play an important role in the Iranian economy (Demirel, Alparslan, Bozdağ & Emirel, 2013).

There are two views on this. The first view is to mistakenly assume that medical tourists want to take advantage of Iran's currency situation, and access Iran’s medical facilities at a very low rate, and should not be allowed to do so. However, world experience has proven this view to be false , because in the long run, the number of medical tourists entering Iran will gradually decrease (Ayoubian, 2018). The second view, which is more scientifically valid, is that with the devaluation of the national currency, the profit gained by medical centers decreases in relation to each individual patient, but instead, more foreign patients flow into the country. In other words, increasing the number of foreign patients can completely neutralize the effect of a reduction to income from individual treatments, and lead to significant profitability for medical centers in the country (Shahbazi, 2019).

By assessing the role of cost, it can be concluded that this factor is present, implicitly or explicitly, across the entire medical tourism industry. Therefore, a destination country should not only pay attention to factors such as quality, infrastructure, technology and culture, but also be cognizant that cost is a determining factor in a medical tourist’s choice of destination.

7. Conclusion

Medical tourism, an opportunity generator that links the two areas of medicine and tourism, is a new form of tourism that has grown significantly in recent years in Iran. One of the key aspects of medical tourism is its impact on competition and a country’s comparative advantage. Today, one of the areas in which developing countries have a lot of competitive advantages is medical tourism. This is why many developing countries, especially in Asia, are responding to this competitive environment by focusing on their marketing and recruitment of medical tourists.

The aim of this research was to assess the effectiveness of the various factors driving medical tourism on the creation of new economic and political opportunities, in the particular case of Azerbaijani medical tourists coming to Iran. The results indicated that medical tourism, due to the attraction of high quality, low cost medical services available in Iran, has created a good opportunity for the people of the Republic of Azerbaijan to acquaint themselves with the cultural and political values ​​of Iran as well as for Iran to strengthen its economic and political structures. Medical tourism is also an effective and powerful tool in the promotion of soft power. In this regard, the attractiveness of the first and second factors can create a good opportunity to introduce Iran's cultural values to Azeri tourists.

Looking forward, the advancement of Iran's political and economic structures requires the attention of its statesmen and their effective use of the current situation. It is important to pay attention to Iran’s capacities. But how could these be leveraged to attain the desired results? Specific strategies are needed to increase the attractiveness of Iran as a medical tourism destination. Iranian policymakers should aim to:

a)    Understand cultural commonalities for enhancing cultural communication between people of Iran and other countries.

b)   Pay more attention to cultural tourism, and the use of Iran’s capacity to familiarize the people of Azerbaijan with its arts, music and cultural products.

c)    Facilitate the necessary conditions for attracting foreign students and provide appropriate spaces for them.

d)   Facilitate travel to Iran as a destination country.

e)    Promote tourism destinations to become acquainted with foreign tourists and create more attractions for them.

f)    Invite elites and artists from countries of origin to participate in conferences and create space for their participation.

g)   Produce cultural products in accordance with cultural commonalities and make them easy to access, in order to facilitate the transfer of cultural values.

h)   Reduce stressful issues, including ethnic and religious differences between people of the countries of origin and destination, to smooth the relationship between the two countries.

i)     Pay attention to historical and linguistic commonalities, in order to facilitate cultural communication.

j)     Adopt political decisions in line with common cultural values.

k)   Ensure the existence and quality of essential medical tourism components including medical service centers, accommodation centers, health care professionals (experienced physicians) and travel service offices. 

l)     Pay more attention to the development of hotel building to increase accommodation capacity.

m) Leverage Iran’s advantage in attracting foreign patients resulting from the devaluation of the IRR against the USDby generating information and advertising to increase the scope of foreign patients’ awareness of Iran's numerous capabilities in the field of medical tourism and boost tourist numbers.

As this research was limited to the examination of medical tourists from the Republic of Azerbaijan, further investigations could focus on tourists who come to Iran from other countries such as Iraq.  It is further suggested that, in the future, an investigation be conducted on the role of spouses and family members who accompany medical tourists.