The Key Role of Logistics in Healthcare Tourism: Challenges and Opportunities

1. Introuduction

The definition presented in academic articles describes healthcare tourism as activities in which tourists travel to a medical destination for at least one night to receive medical services [1]. This type of tourism has experienced remarkable growth in recent years due to increasing demand for higher-quality or more affordable healthcare services in different countries. The background of this subject has a long history. In the past, people traveled to benefit from the healing properties of natural remedies. For example, in ancient Rome, public baths and hot springs were introduced as centers for relaxation and health. In Eastern civilizations, traditional treatment methods such as acupuncture in China and naturopathy in India significantly attracted people from other regions. These journeys, often undertaken for medical and religious reasons, sometimes formed a combination of healthcare tourism and spirituality. During the Middle Ages, traveling to sacred places to treat physical and mental illnesses became popular. Places such as churches and monasteries were known as healing centers, and people from distant regions would visit these locations in search of cures. Such journeys reflected the connection between religious beliefs and faith in divine healing.

In the twentieth century, with significant advances in transportation and medical science, healthcare tourism took on an international form. Europe became one of the leading centers of this type of tourism due to its advanced technologies and modern surgical practices. However, after the World Wars, many medical infrastructures in war-affected countries were destroyed, and residents of these regions traveled to neighboring countries to receive healthcare services. Healthcare tourism became an important factor in the reconstruction and improvement of people's quality of life after the wars.

For many years, the United States and Canada were recognized for their medical innovations and specialized treatments for complex diseases and surgeries. Countries like Germany and Switzerland were considered top healthcare tourism destinations in Europe due to their advanced hospitals and expertise in treating complex and cosmetic conditions. However, in the 21st century, the focus of healthcare tourism significantly shifted to Asian countries. Nations such as India, Thailand, Malaysia, China, and South Korea became prominent centers in this industry due to economic reasons and the provision of quality healthcare services. These countries, by offering lower treatment costs, advanced infrastructure, and a combination of modern services with traditional medicine, have attracted many health tourists from other nations, including developed countries.

Healthcare tourism in Iran officially began in the early 2000s, aiming to attract patients from neighboring countries such as Iraq, Afghanistan, Azerbaijan, and the Persian Gulf states. This movement was shaped by focusing on developing healthcare infrastructure, improving the quality of medical services, and extensive international advertising. Lower treatment costs compared to Western countries and even some regional states, access to experienced and specialized doctors, and the provision of services such as cosmetic surgery, infertility treatments, organ transplants, and orthopedic surgeries have given Iran a special position. Furthermore, medical centers with international standards, the use of modern medical technologies, and natural capacities (such as hot springs and salt therapy) have supported this position. Iran's cultural and religious proximity to neighboring countries is another key factor in attracting foreign patients and expanding healthcare tourism. Fig. 1 shows the names of the world's top 10 medical tourism destinations based on value

2. Logistics

Logistics refers to planning, executing, and controlling the flow of goods, services, and information from the point of origin to the final destination. This process includes procurement, warehousing, transportation, distribution, and inventory management. Its dimensions include inbound logistics (related to the supply of raw materials), internal logistics (management of warehousing and production), and outbound logistics (distribution of final products) [3]. In the supply chain, logistics management is vital in connecting all stages, from supplying raw materials to delivering the final product to the customer. The main goal of logistics management is to reduce costs and increase efficiency throughout the supply chain.

3. Logistics in Healthcare Tourism

Logistics in healthcare tourism is one of the key factors in the development of this industry, involving the management and coordination of all processes related to transportation, accommodation, and provision of medical services to health tourists [4]. This concept encompasses a wide range of activities, from travel planning and the transfer of international patients to the timely delivery of temperature-sensitive medicines and medical equipment (cold supply chain). Due to the specific needs of this type of tourism, logistics in healthcare tourism require very high accuracy, speed, and coordination.

4. Literature Review

In this section, a literature review based on various articles in the field of healthcare tourism logistics is presented, with a summary of these articles provided in Table 1. All these articles are from reputable Q1 journals.

Preliminary studies in medical tourism indicate that environmental and media factors play a significant role in tourists' decision-making. Heung et al. [7] examined the impact of negative environmental news in the media on the selection of medical tourism destinations. They found that tourists prefer destinations with higher levels of safety and security when faced with such news. This study, considering uncertainties, aims to optimize the profitability and sustainability of the supply chain. Subsequently, Fetscherin and Stephano [8] addressed the influence of global crises such as pandemics on tourism decisions, emphasizing the importance of tourism potential and logistical efficiency in these decisions.

Rezaeiahari and Khasawneh [9] focused on treatment planning for medical tourism patients and used a hybrid optimization algorithm to reduce patient waiting times. Jaapar et al. [1] studied dental tourism in Malaysia. They identified two groups of dental tourists: those who travel specifically for dental treatments and migrants who return home for holidays and include dental care in their trip. The primary motivating factors include dental care quality, access to information, and cost savings.

In sustainability, Ahmadimanesh et al. [11] designed a sustainable supply chain for dental tourism. Their research identified key factors affecting dental tourists' satisfaction, such as accurate information access, dental service quality, and reasonable costs. Nilashi et al. [10] studied the impact of awareness and social trust on healthcare tourism intention based on forest tourism, highlighting that awareness about health preservation and social trust are influential factors. Forest-based healthcare tourism refers to travel to forests and natural areas to benefit from the health and therapeutic advantages of natural environments, often including activities like forest walks, stays in natural accommodations, and nature-based health services aimed at improving physical and mental health, reducing stress, and enhancing quality of life.

With the emergence of COVID-19, research focus shifted towards analyzing the impacts of the pandemic on supply chains and tourism decision-making. Cham et al. [12] explored travel motivations and barriers in the post-COVID era, identifying push factors like stress and pull factors like improved hygiene as influential in tourist decisions. Hassan and Salem [13] developed a mathematical model for the dental tourism supply chain, demonstrating that optimizing the capacity of accommodation and treatment centers increases profits. Motevalli and Paydar [14] investigated the impact of safety measures at Sharm El-Sheikh airport on tourists' decisions, highlighting the importance of security considerations in the post-pandemic period.

Recent studies have analyzed the structures and indicators of medical tourism. Tănase et al. [16] examined Generation Z's preferences for rural tourism destinations, finding authenticity, cultural heritage, and nature as key attraction factors. Gajić et al. [17] studied factors affecting acceptance of medical tourism in Malaysia, identifying significant human, technological, and organizational aspects. Ekonomou et al. [18] designed a crisis management model for tourism during COVID-19, recognizing tourist entry control as a key factor in disease management.

Moreover, Li and Wen [19] developed a comprehensive index to evaluate countries' attractiveness for medical tourism, covering treatment services, quality, safety, infrastructure, and patient experience, useful for comparing countries at various levels. Srisawat et al. [4] investigated social and national factors influencing Malaysia's image as a medical tourism destination, finding most factors significant except the impact of country-generated social media news. Zhou et al. [6] studied word-of-mouth communication among tourists in shaping urban tourism destination reputation in China. Their research analyzed factors influencing consistency in tourists' reputation judgments and word-of-mouth, emphasizing attention to local food, the natural environment, and the social atmosphere. Results showed these factors significantly affect consistency in positive and negative reputation judgments.

From an economic perspective, Kouaissah and Hocine [15] introduced the XOR-BWM method to assess COVID-19 impacts, revealing that tourism, industry, and health sectors in Italy suffered the most. Babaei et al. [20] proposed a two-stage framework: first, suppliers are evaluated for sustainability using weighted ideal programming, fuzzy, and robust stochastic methods; second, an outsourcing strategy is designed by combining ANP-DEMATEL methods. Their model, applied in Tehran, demonstrated a 40% increase in supply chain profitability.

Charati et al. [21] studied sustainable supply chain design for dental tourism, considering waste treatment. They determined optimal locations, numbers, and capacities of dental clinics and accommodations, addressing economic, social, and environmental sustainability. Results suggest governments should increase subsidies to individual dentists to improve waste treatment facilities and transportation.

Finally, Lin et al. [22] studied the task allocation and routing problem for a heterogeneous fleet of uncrewed aerial vehicles (drones) in the context of emergency health services. This research aims to maximize the total profit obtained from performing a set of delivery and pickup tasks involving critical medical supplies and laboratory samples under emergency conditions. To this end, the problem was modeled as a Mixed-Integer Linear Programming (MILP) formulation, incorporating constraints such as time windows, payload capacity, drone altitude, and flight range. The primary decision variable is the optimal selection of the combination of drone, task, and center for each mission. To solve this NP-hard problem, a hybrid Q-learning-based Adaptive Large Neighborhood Search (QALNS) algorithm based on adaptive large neighborhood search and Q-learning reinforcement learning was developed. By employing the learning mechanism, this method showed significant improvements in convergence speed and solution quality compared to Gurobi and classic ALNS, providing, on average, 5.49% and 6.86% better performance in numerical tests, respectively.

5. Research Findings

6. Future of Healthcare Tourism

Healthcare tourism is moving toward digitalization and the adoption of technologies such as telemedicine and artificial intelligence, which will facilitate easier access and management of treatments. Demand for specialized treatments such as robotic surgeries and genetic therapies is increasing, and countries with advanced infrastructure are expected to become the main healthcare tourism hubs.

Personalized services will enhance patient experience. Sustainability, adherence to environmental and ethical standards, and focus on patient welfare will be key success factors in this industry.

Word-of-mouth advertising is crucial in healthcare tourism because it directly affects the destination's reputation. High-quality medical and accommodation services, information transparency, and cultural and natural attractions strengthen this advertising. Positive patient experiences quickly spread through social networks, influencing others' decisions. Utilizing digital tools for word-of-mouth can increase trust and attract international patients. Transparent sharing of treatment processes and outcomes also improves the destination's reputation.

7. Conclusion and Suggestions for Future Studies

Healthcare tourism involves traveling to other countries or regions for medical, health, and therapeutic services. Motivations include lower treatment costs, high quality and variety of medical services, and access to advanced technologies. Benefits for travelers include affordable treatments, advanced surgeries, and internationally standard medical services. Many countries offer a blend of modern and traditional medicine, which attracts certain patient groups. For host countries, healthcare tourism boosts the economy, creates employment, and improves healthcare industries. Patients benefit from combining treatment with tourism experiences.

Despite significant progress, challenges and gaps remain, notably inadequate attention to environmental aspects. Reducing environmental harm, resource management, and sustainable supply chain models must be prioritized. Proposed research areas include designing reverse logistics for medical waste management and facilitating foreign patient transfers. Using circular economy models to minimize waste and developing integrated systems for better coordination among tourism and health sectors (such as patient discharge and transfer to medical hotels) are critical. Optimizing medical transport routes through hub and network models to better manage crises and health conditions can improve services.

Lastly, developing new objective functions that ensure fairness in-service distribution and adequate coverage for tourists is an important future research priority, especially for countries relying on healthcare tourism as an economic growth pillar. It can significantly improve tourist satisfaction and system efficiency.