the emerging phenomenon of so - called health tourism has been in europe since the time of ancient greece and rome ( 12 ) . the term  health tourism  was introduced in 1987 by goodrich ( 3 ) .
this multi - faceted topic has been considered as an academic one , from mid-1990s .
in addition to some books introducing the tourist targets , there are papers criticized the heath tourism and its different aspects ( 48 ) . gun et al .
therefore , to achieve a complete understanding of health tourism , there is a need to study changes over time .
the whole process starts from 16 century , which meant a trip to use mineral water supplies , and then use the newly established spa to improve health . currently , we have expanded its meaning which embraces not only the previous meaning but also pre - arranged trip to the hospital for treatment objectives ( 1013 ) .
today , health tourism , embraces three separate categories including medical tourism , curative tourism , and wellness tourism .
this type of tourism can be seen in all ages , but mostly in older and retired tourists from western countries . on average , women of 45 years age are clients of this type of tourism .
these customers typically have high incomes , high levels of education and a lot of time for tourism and personal needs ( 14 ) . currently , health tourism is a major topic of the combination of two components which requires the cooperation of several services running simultaneously , and surveillance organization monitoring and coordinating an enterprise network in the country ( 15 ) . for the first time  medical tourism ,  was considered in iran by the ministry of health in 2002 .
islamic countries health tourism congress in mashhad ( 2010 ) considered iran after the jordan of the highest potential in health tourism in these countries .
there are several medical centers ; specialty and subspecialty , relatively low cost , enjoyment of natural resources , proximity to arab markets and similarity of culture and language with the some neighboring countries are including advantages in attracting foreign patients and medical tourists in iran . despite the relatively good state of skilled practitioners and efficient health and wellness in the country , attracting tourists for health services hardly had been in the center of authorities thoughts . only in recent years , iranian cultural heritage and tourism organization and the ministry of health , have planned and studied in this context .
previous studies conducted in iran shows that this country encompasses the most abilities to attract tourists looking for treatment and enjoy sightseeing simultaneously ( 16,17 ) . because of the lack of comprehensive planning system for health tourism , all related studies have tried to understand the different aspects of this process and provide practical solutions and suggestions which are constructive in terms of planning and strategy of medical tourism ( 1821 ) .
shiraz , as a famous city not only in iran , but throughout the world , although has established itself as a high rank place as for having the most pleasant attractive monuments and sightseeing , but unfortunately has not gone through deep survey in terms of absorbing patients . annually
hundreds of patients from neighboring countries enter shiraz in hope of seeking health and attractive places .
nemazee and khodadoost hospitals , in fact , are famous names among hospitals for many residents of adjacent countries .
so far , scientific appraisal could not make clear all positive and negative aspects of this arena .
this study aimed to clarify all aspects of health tourism in shiraz city due to studying the demand situation that means health tourists needs in last years .
furthermore , this study would like to fill the gap of functional data necessary for health authorities and policy makers .
shiraz as the capital of fars province is the fourth most populous city in iran and has a temperate weather .
northwest axis of the town because of the natural landscape and temperate climate has been introduced as the health tourism route by the tourism and cultural heritage organization .
shiraz has one of the oldest and greatest archaic places in the world , persepolis , which caused this city to be very famus for tourists around the world .
geographical and cultural proximity to the persian gulf area countries , foreign direct flights , in addition to be confidence to physicians in shiraz , have provided a favorable matrix for the promotion of health and medical tourism planning .
in addition to shiraz university of medical sciences as a prominent unit , there are 12 private and 22 governmental hospitals .
this city has been known for liver transpiration operations from almost half a century ago .
the efficient authorities on the topic were identified through the hospitals engaging in medical tourism .
the research was based on theoretical sampling through which the experienced people of extensive knowledge on medical tourism were interviewed .
then the first subjects were asked to introduce more people engaging in that topic based on a snowballing method .
accordingly , the questions were categorized based on the research objectives . altogether , 50 respondents were interviewed . for the uniformity of the results ,
all replies were included in delphi questionnaire , and then it was sent to 30 of respondents , which 25 of them replied it .
the process of recognizing the demand for health tourism in shiraz was based on the three principles including ( i ) gathering the number of foreigner health tourists ; ( ii ) identification of the destination country and ( iii ) knowledge on the nature of occupational therapy . determining
the supply sector of health tourism has been considered more difficult due to its different parts and tools ( 22 ) .
therefore , due to scattering angles presented in supply section , the demand and supply model ( 9 ) was utilized to categorize the supply services ( fig .
given the importance of cultural factors in this research , the  socio - cultural index  was considered as a control and efficient indicator in all steps of the recognizing the supply .
the model provides conditions that extensive discussion can be analyzed in relation to the product , services or related schedule .
then the output of this chart was designed in ( swat ) based questionnaire and was sent to top ten experts on medical tourism for scoring .
shiraz as the capital of fars province is the fourth most populous city in iran and has a temperate weather .
northwest axis of the town because of the natural landscape and temperate climate has been introduced as the health tourism route by the tourism and cultural heritage organization .
shiraz has one of the oldest and greatest archaic places in the world , persepolis , which caused this city to be very famus for tourists around the world .
geographical and cultural proximity to the persian gulf area countries , foreign direct flights , in addition to be confidence to physicians in shiraz , have provided a favorable matrix for the promotion of health and medical tourism planning .
in addition to shiraz university of medical sciences as a prominent unit , there are 12 private and 22 governmental hospitals .
this city has been known for liver transpiration operations from almost half a century ago .
the efficient authorities on the topic were identified through the hospitals engaging in medical tourism .
the research was based on theoretical sampling through which the experienced people of extensive knowledge on medical tourism were interviewed .
then the first subjects were asked to introduce more people engaging in that topic based on a snowballing method .
accordingly , the questions were categorized based on the research objectives . altogether , 50 respondents were interviewed . for the uniformity of the results ,
all replies were included in delphi questionnaire , and then it was sent to 30 of respondents , which 25 of them replied it .
the process of recognizing the demand for health tourism in shiraz was based on the three principles including ( i ) gathering the number of foreigner health tourists ; ( ii ) identification of the destination country and ( iii ) knowledge on the nature of occupational therapy .
determining the supply sector of health tourism has been considered more difficult due to its different parts and tools ( 22 ) . therefore , due to
scattering angles presented in supply section , the demand and supply model ( 9 ) was utilized to categorize the supply services ( fig .
2 ) . given the importance of cultural factors in this research , the  socio - cultural index  was considered as a control and efficient indicator in all steps of the recognizing the supply .
the model provides conditions that extensive discussion can be analyzed in relation to the product , services or related schedule .
then the output of this chart was designed in ( swat ) based questionnaire and was sent to top ten experts on medical tourism for scoring .
using interviews conducted in this study , it was found that active hospitals on attraction of foreign patients averagely admitted 15 and 50 foreign patients monthly and annually , respectively .
arab countries in the persian gulf were detected as the main marketing for shiraz medical tourism .
accordingly oman encompassed the highest rate with 20% of admitted patients . according to fig .
3 , eye treatments with 30% and orthopedic therapies with 6% were demonstrated as the highest and lowest rates in terms of foreign patients needs .
the tourist attractions of shiraz , according to health experts were divided into two parts : physical and non - physical .
each part of the table 1 shows the importance of each section for arrived patients .
these items have been numbered and inserted in the table based on their importance . the most important factor in physical attractiveness
it was found that world - famous historical attractions of shiraz were not in the center of consideration for arabs residing in the persian gulf countries and only religious places were welcomed by them . regarding non - physical attractions , 80% of replies determined that closeness of cultural , and religious beliefs and familial relationships on one hand and trusting to iranian physicians on the other hand were amongst the most reasons for selecting iran as a destination for medical tourism by these patients .
besides , we found that economical and financial factors had the minimum effect on their decision to select a destination . in the field of transportation ,
the high quality services were detected as the main pillar for attraction of health tourists especially for patients coming from arab countries settled nearby the persian gulf .
table 2 shows that providing a complete package including all aspects of tourism services constituted an important point for improving the outcome with 72% rate .
moreover , regarding to accommodation , 84% of patients preferred to stay in luxury hotels ; instead , some of them coming with family preferred the hotel apartments or furnished hotels . ancillary services in this study
the need for tourists to spend recovering in the garden area with fresh air , with ease in visa issue was of the same importance ( table 2 ) . among the most effective advertising and marketing methods that were selected by experts , media activities , with 96 percent of respondents encompassed the most important factor in attracting foreign patients .
in addition , a sales office in the country of origin with the language of that country , with 88% of comments was identified as the second most effective marketing method .
furthermore among the advertising methods , the existence of information and advertising office in origin countries showed the greatest impact on attraction of the city s tourists .
based on a thorough understanding of the strengths and weaknesses of health tourism in shiraz , demand and supply conditions were incorporated using the target network model and were included in four methods of create , maintain , abstinence and review ( table 3 ) .
this study was conducted to verify the potential aspects of health tourism in shiraz city , southern iran . due to a variety of factors
although the outputs extracted from this study are specific to the region , yet , planning and general methods presented in the paper is applicable to other regions of the country as well .
the results showed that among the presented facilities in this city , eye care had the highest rank in the context of this demand , while the country of oman could get the top rank in terms of countries of the highest medical tourists .
tribal sheikhs and residents of oman from long time ago have had constructive relations with iran
. persisted sand storms caused people of oman to travel to iran many times per year .
successful reputation in the field of infertility and treatment by a muslim physician caused arabs to trust an iranian physician which justifies traveling 16% of them to iran for medical tourism affairs . from collected data of our study , we can conclude that although geographical distance has a significant impact on the choice of destination therapy , yet this factor is affected by economical , environmental , cultural and social factors .
the realities of social and cultural differences have persuaded muslim countries to manage their important care necessities within another muslim country . in the context of intercultural adaptation on tourism ,
one out of every 10 people is able to adapt to foreign conditions ( 23 ) .
preparation and planning , provides tourist trips in the face of possible problems ( 24 ) .
another study showed that the patients were looking for medical care of high quality and reasonable price ( 25 ) .
our results showed that patients who traveled to shiraz had no concern on the latter fact but mostly considered the prominent muslim physicians , similar cultural affairs and close distance as the most standing factors in selecting this city .
our results showed that despite the reputation of nemazee hospital , tourists nowadays prefer to seek treatment in private hospitals in shiraz .
the survey also found that tourists are looking for luxury accommodation and prefer hospitals so called 5 stars ( 26 , 27 ) .
this study showed that the patients were looking for medical care of high quality and reasonable price . according to kaufman and mueller ( 22 ) , the conditions for health tourism hotels are as follows : 
35 star accommodations , health information , health care , personal and cultural programs and a variety of amenities .
 destination promotion is one of the marketing and manufacturing of marketing mix , it is important in recognizing and developing destinations ( 28 ) .
evidence suggests that an office of information and related advertisements in destination media would have an important affect on attracting the patients to shiraz .
a research showed that among the variables of notification mechanism , just the advertising media had a significant correlation with attracting the medical tourists ( 29 ) .
this implies that the advertising opportunities in the international media in the field of health care , physicians , high quality services , and technology can lead to attracting the medical tourists ( 30 ) .
for example , prepare pictures of health centers and putting them up at the airports and terminals ( 31 ) . in this study ,
the activities of middlemen , so called  brokers  , were identified as the main attraction factor . due to the familiarity in language and having cultural relations with applicants , these channels show great ability in marketing , attracting and encouraging people to select shiraz for health tourism affairs . all outputs of this study are included in table 3 which contains functional solutions to authorities . in creation section , a bird s eye view on it implies that health tourism in shiraz , although successful in meeting many requirement in this arena , is in a situation which demands different infrastructures to not only satisfy the present set of tourists , but to promote the attraction more numbers of them as much as possible . in the section of maintenance , previous results have been confirmed and it might be concluded that health tourism in shiraz and iran , has its base on close relation between origination and destination , as well as the popular fame of iranian physicians .
some studies imply that neglecting the proper planning , not only will result to stop the process , but will cause to demolish even this small package and considering the competitive situation of present period , consequently the patients will be guided to other islamic countries .
factors mentioned in restrain section not only have no indication in health tourism system of shiraz but are not requested by applicants . although , these factors might improve the rate of attraction of health tourists but considering that demand section does not need them and executive power should be implemented for other parts , investment on this category only waste the power and energy of the organizations .
eventually , revision section , although named as deletion in the main model of targets network , but due to importance of all points in planning for health tourism , nothing should be neglected . deep looking into the case shows that this category has not been considered properly by demand section , so not only it should not be omitted but needs more attention in programming .
our findings demonstrated that implementing 4 strategies in planning for medical tourism in shiraz would result into significant improvement of attraction more patients as follows : 
 allocation the responsibility of the executive affairs to specific section to remove the weak points of managing- legislation.proper monitoring of convalescence period and presenting variable packages of tourism.policy making on absorbing the foreign investments to establish the project of shiraz health town.propaganda expands based on cultural closeness between supply and target bazaar , in addition to branding shiraz medical ability .
allocation the responsibility of the executive affairs to specific section to remove the weak points of managing- legislation .
policy making on absorbing the foreign investments to establish the project of shiraz health town .
propaganda expands based on cultural closeness between supply and target bazaar , in addition to branding shiraz medical ability .
ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc ) have been completely observed by the authors .
 background : the aim of the present study was to appraisal the prose and cone of shiraz city in terms of its potential in the context of health tourism.methods:the statistical sample included medical and health tourism sector in the city of shiraz in the northwest of fars province , south of iran . 
 the efficient authorities on the topic were identified through the hospitals engaging in medical tourism . 
 the research was based on theoretical sampling through which the experienced people of extensive knowledge on medical tourism were interviewed.results:active hospitals on attraction foreign patients averagely admit 15 and 50 foreign patients monthly and annually , respectively . 
 arab countries in the persian gulf were detected as the main marketing for shiraz medical tourism . 
 oman encompassed the highest rate with 20% of admitted patients . 
 eye treatments with 30% and orthopedic with 6% were demonstrated as the highest and lowest rates in terms of foreign patients needs , respectively . 
 closeness of cultural and religious beliefs and familial relationships on one hand and trusting to iranian physicians on the other hand were amongst the most reasons for selecting iran as a destination for medical tourism by patients.conclusion:implementing 4 strategies on monitoring medical tourism would result into significant improvement of attracting more foreigner patients not only into shiraz but all around iran . 
 these items have been discussed in the text . 
Introduction
Materials and Methods
Study area
Collecting data
Analyzing data
Results
Discussion
Conclusion
Ethical considerations