256 Int. J. Society Systems Science, Vol. 9, No.

3, 2017

SWOT-AHP analysis in medical tourism area of Kerala

M.N. Anish, P.B. Dhanish and R. Sridharan*

Department of Mechanical Engineering,
National Institute of Technology Calicut,
673601, India
Email: mn_anish@rediffmail.com
Email: dhanish@nitc.ac.in
Email: sreedhar@nitc.ac.in
*Corresponding author

Abstract: This paper identifies and prioritises strengths, weaknesses,

opportunities and threats (SWOT) pertaining to the medical tourism sector of
Kerala. Twenty one factors corresponding to SWOT are identified through
literature review and expert opinion. The pair-wise comparisons used in the
analytical hierarchy process (AHP) help to analyse the situation more precisely
than the standard SWOT analysis. The most crucial factors of SWOT are
identified through the hybrid SWOT-AHP method. Initially, the ranking of
each SWOT group is identified. The result obtained for each of the parameters
of SWOT is 42%, 12%, 29% and 17%, respectively. This hybrid SWOT-AHP
method aids in determining the relative weights of SWOT. ‘Strength’ emerges
as the most important group and ‘medical doctors of international fame and
repute’ of strength group emerges as the most important factor. The identified
factors of SWOT groups aid in developing appropriate strategies for the
medical tourism sector of Kerala.

Keywords: medical tourism; Kerala; SWOT; analytical hierarchy process;

AHP; strategy.

Reference to this paper should be made as follows: Anish, M.N., Dhanish, P.B.
and Sridharan, R. (2017) ‘SWOT-AHP analysis in medical tourism area of
Kerala’, Int. J. Society Systems Science, Vol. 9, No. 3, pp.256–276.

Biographical notes: M.N. Anish is a Research Scholar in the Department of

Mechanical Engineering, National Institute of Technology Calicut, India. His
areas of interests include service quality and maintenance engineering.

P.B. Dhanish is an Assistant Professor in the Department of Mechanical

Engineering, National Institute of Technology Calicut, India. His areas of
interests include metrology and quality.

R. Sridharan is a Professor of Industrial Engineering in the Department of

Mechanical Engineering at the National Institute of Technology Calicut, India.
His research interests include modelling and analysis of decision problems in
supply chain management, total quality management, job shop production
systems and flexible manufacturing systems.

This paper is a revised and expanded version of a paper entitled ‘SWOT

analysis in medical tourism area of Kerala’ presented at CPIE-2016, NIT
Jalandhar, 19–21 December 2016.

Copyright © 2017 Inderscience Enterprises Ltd.

 SWOT-AHP analysis in medical tourism area of Kerala 257

1 Introduction

Movement from one country to another in pursuit of better treatment is a common

practice. Lee and Spisto (2006) state that medical tourism refers to travel activities that
involve medical procedures or activities to promote the wellbeing of the patient. The
main intentions of such travels are low cost treatment and less delay to get treatment in a
foreign country. Snyder et al. (2010) state that medical tourism involves travelling across
international borders for receiving medical care. Fostering the medical tourism sector
encourages the other allied sectors namely, transportation and hospitality. The
economical and political climate of the country is also suitable for a rapid growth of
medical tourism. Badwe et al. (2012) state that medical treatment costs in India are
between one-third and one-half rates of that of Singapore and Thailand. Hence, India is
regarded as one of the most important destinations for the medical tourists. The
Government of India promotes medical tourism through several schemes. Medical
tourism increases the chance of employment and is also a good source of revenue
generation. The advantage is that even a remote place of the country has enough potential
to become a good hub of the medical tourism sector. Kerala is in the southern part of
India where the climatic conditions are moderate almost throughout the year. High
literacy rate, talented doctors and nurses and ability to provide high quality treatment at
lesser costs are some of the other advantages for Kerala.
In India, there are a large number of hospitals in the private sector and the facilities of
these hospitals can be used to attract international patients. Many other counties also
concentrate on the health sector and several studies have been conducted in the related
areas. Parker and Pant (2011) describe the intricacies of an ageing population in Nepal
and focus on examining the various health and service implications to the nation. They
highlight the challenges to Nepali society in terms of meeting the needs of an ageing
population and creating a policy environment that ensures these needs are met. Tekieh
et al. (2015) identifies significant factors in healthcare coverage based on models
developed using decision trees, neural networks, and k-means. The models are built and
tested on a real dataset from the medical expenditure panel survey databases of the USA.
The significant factors include access to care, age, poverty level of family, and
race/ethnicity.
In order to attract foreign patients, a high quality is required to be maintained in the
general living conditions of the host country. A number of factors affect the quality of
life. Ridderstaat et al. (2013) propose an analytical framework for describing the
relationship between tourism development, quality of life of residents, and shocks or
disturbances. The researchers suggest that their proposed framework provides a better
understanding of both tourism development and quality of life. The knowledge of the
possible implications of shocks or disturbances provides prospects for improving the
preparedness and responsiveness of actors, while potentially speeding up the recovery
after unexpected events. Using a case study of an Indian city, Singh (2015) determines
the major factors that affect the quality of life. The responses obtained from a
questionnaire-based survey have been analysed using principal component analysis and
descriptive analysis. Personal, social and economic well-being is found to be the most
important determinant of the quality of life in Lucknow. The other factors include
ambient environment, transport infrastructure and police services, housing facilities,
social infrastructure, utility services, and social environment.
258 M.N. Anish et al.

Strategic planning has importance in all the sectors. Luić and Galinec (2015) report
on the research conducted to analyse the social dimension of short-term and long-term
alignment in the higher education system of Croatia. It is found that strategic planning of
the integrated business and information system significantly depends on long-term
management alignment, directly influenced by common knowledge on domain and
financing. Decision making is vital to formulate strategies. Interests of all the parties
should be considered while taking the decisions. Kira (2016) proposes a mechanism that
brings together the perspectives of shareholders and stakeholders.
Strategies have roles in improving the quality of service also. Snider et al. (2011)
explore potential strategies for service quality improvement for the James E. Walker
Library at the Middle Tennessee State University. The study examines the services of
library and provides suggestions for employees. Li et al. (2016) investigate the
correlation between the passenger volume and space distribution in a railway system.
Ifinedo (2015) describes a study that enriches the information provided in the 2012
Deloitte Touche Tohmatsu Limited security survey. The researcher observes that
contextual factors such as national transparency levels, ethical behaviour of firms and
technological readiness have positive relationships with information security threats and
controls.
Better service quality leads to generate behavioural intentions such as repurchase in
favour of the organisations. Wang et al. (2011) investigate the effect of online reviews on
consumer intention to purchase on websites. The online review attributes identified are:
1 intrinsic quality of online reviews
2 number of online reviews
3 reviewer reputation
4 review timeliness.
The researchers conclude that intrinsic quality of online reviews and number of online
reviews has a positive effect on consumer purchase intention, while reviewer reputation
and review timeliness have no such influence. Meziani (2014) proposes an approach
which considers ‘sustainable indicators’ and ‘geographical information systems (GIS)’ as
decision making tools. The study combines these to generate a local sustainable
development policy for the transportation sector in the city of Ghardaia, Algeria. The
study shows that the factor ‘accessibility’ needs special attention.
External factors (opportunities and threats) and internal factors (strengths and
weaknesses) exist in every sector/organisation. Dehouche (2015) evaluates a set of
project proposals and then selects the best projects among them. The above study finds
that the project portfolio selection methodology depends on the section in which the
projects are carried out. Dehouche (2015) proposes a multi-criteria methodology based on
strength, weakness, opportunity and threat (SWOT) analysis. Similar to that of other
sectors, strength and weakness affect medical tourism sector also. Strengths can be used
to achieve the objectives and weaknesses can be shored up. Opportunities and threats
(political, economical, social or environmental) also affect medical tourism sector.
Opportunity factors are in favour and help the growth of the medical tourism sector.
Factors that are against the medical tourism sector act as threats. Strength indicates the
areas where the organisation has certain advantages in achieving the objectives and
weaknesses associated with the organisations prevent from achieving the desired results.
 SWOT-AHP analysis in medical tourism area of Kerala 259

Opportunities help in achieving benefits of the medical tourism sector, and threats are
detrimental in achieving the desired results. It is required to tackle threats against the
medical tourism sector. SWOT method can be used to identify the strengths, weaknesses,
opportunities and threats associated with medical tourism sector.
Analytic hierarchy process (AHP) helps to arrange the factors in a hierarchical
structure and to prioritise them for an effective decision making. Sambasivan and Fei
(2008) emphasise the role of AHP in making decisions and in developing strategies.
SWOT-AHP hybrid method is used to measure the priorities or weights of the factors in
the medical tourism sector identified through SWOT analysis. Strategies for the medical
tourism sector can be developed based on SWOT-AHP analysis. Strategies for
maximising strengths and opportunities and also for minimising weaknesses and threats
can be framed. Thus, the objectives of the present study are as follows:
• Identify the SWOT factors in the medical tourism sector of Kerala.
• Determine the relative priorities of SWOT groups and the factors of SWOT groups
using the hybrid SWOT-AHP method.
To the best knowledge of the authors of this paper, the present study is the first to study
on the application of the hybrid SWOT-AHP method in the medical tourism sector of
Kerala. The rest of the paper is structured as follows. Section 2 provides a review of the
relevant literature. Section 3 explains SWOT analysis method and the hybrid
SWOT-AHP analysis method. Section 4 deals with the estimation of weights using the
hybrid SWOT-AHP analysis method. Section 5 highlights the inferences and the
managerial implications of the study. Section 6 provides the conclusions.

2 Literature review

A number of research studies have been reported in the literature to identify the SWOT
factors and also to analyse the use of hybrid SWOT-AHP method. A comprehensive
review of the literature on SWOT analysis, AHP method and SWOT-AHP method is
presented in the following sub-sections.

2.1 SWOT analysis

SWOT analysis includes a brain storming session to identify the key variables that affect
a firm’s performance. The SWOT method allows us to analyse and categorise the
associated factors into internal factors (strengths and weaknesses) and external factors
(opportunities and threats). The SWOT analysis helps to determine the following.
• The strengths and the opportunities that aid in achieving the objectives.
• The weaknesses and the threats that adversely affect the organisation/sector.
Kangas et al. (2001) opine that the aim of SWOT analysis is to develop and adopt a
strategy that results in a good fit between the internal and external factors. Kangas et al.
(2001) have used SWOT groups and factors for developing the investment strategy for
Finnish forest industries in North America. Sharma (2005) reports on a SWOT analysis in
the health education profession and discipline in India. Akca (2006) identifies the
260 M.N. Anish et al.

performance of firms in the rural tourism sector of Turkey using SWOT analysis and
explains the constraints and future possibilities of rural tourism in Turkey. Kalali et al.
(2011) identify the effective factors for the failure of strategic decision implementation in
Iranian health service sector. The dimensions identified are context dimension, content
dimension, operational dimension and structural dimension. Levine and D’Agostino
(2012) uses SWOT model on data retrieved from a sample of non-profit administrators of
New York City to determine the challenges and benefits of in US non-profit
organisations during the economic downturn. The study finds that although money was
allocated for strengthening the communities, many non-profit organisations remain under
funded. Woratanarat and Woratanarat (2012) observe that SWOT analysis is one of the
most popular analytical tools used for intelligence analysis. They assess medical student’s
attitude using SWOT. Cinar et al. (2013) study the impact of decentralisation in the
health services in Turkey through SWOT analysis by comparing the public health
activities of pre and post decentralisation period. They report that decentralisation is an
important issue of the strategic management operations.

2.2 Analytic hierarchy process

AHP is a systematic scoring method developed by Saaty (1980) for computing the
weights of the measured attributes. According to Saaty (1990), AHP uses pair-wise
comparisons of attributes using a nine-point scale. AHP enables decision makers to
assign a relative priority to each factor through pair-wise comparisons. AHP involves
arranging the factors in a hierarchical structure and prioritising them for decision making.
Oddershede et al. (2007) present a decision model based on AHP to prioritise the
activities that support the development of a rural area in China. Jordan and Daim (2008)
report on the development of a hierarchical decision model based on AHP for predicting
the best wheat variety to plant for maximising the profit. The proposed model consists of
four levels with the mission of maximising profitability forming the first level. The goals
such as quality, yield and operating costs comprise the second level of the hierarchy. The
third level consists of grain quality, milling quality, end-product quality, pest resistance
and seed costs. These five form the key strategies. The wheat varieties (alternatives)
constitute the lowest level of the hierarchy. Pair-wise comparisons are conducted to
evaluate the relative importance of each strategy with respect to the goals as well as the
importance of the three goals on the overall project mission.
Using AHP, Sambasivan and Fei (2008) find the relative weights and priorities of the
critical success factors for the implementation of ISO 14001 based environmental
management system in Malaysia. The results of the study indicate that the critical success
factors in the order of importance are management research, organisational change, and
technical aspects, external and social impacts. Saen and Azadi (2009) state that
complexities inherent in the evaluation process and lack of structured information make
the evaluation of strategic alternatives a difficult task. They propose a method known as
super-efficiency method for ranking alternative strategies without relying on weight
assignment by decision makers. Strategies are considered as decision making units. In the
data envelopment analysis method, efficient decision making units cannot be ranked.
However, Saen and Azadi (2009) show that super-efficiency method is capable of
ranking both efficient and inefficient decision making units. Generally, there are various
methods for voters to articulate their preferences on a set of candidates. In the literature,
many methods have been proposed to discriminate among efficient candidates. Based on
 SWOT-AHP analysis in medical tourism area of Kerala 261

a voting model, Soltanifar et al. (2010) develop a methodology to rank the ranking
models for the performance indices of efficient candidates obtained using data
envelopment analysis only.
Levary (2011) uses the AHP method for evaluating and ranking medical tourism
destinations. Agha (2012) combines AHP and preference ranking organisation method
for enrichment evaluations (PROMETHEE) to study the problem of crop planning on
Government lands in Gaza as a multi-criteria decision making problem. The goal of the
study is to rank crops by comparing the crops with respect to seven main criteria, namely
economical, financial, marketing, environmental, technical, political and social criteria.
The results of the study show that in normal economy condition, crops such as
vegetables, citrus and export crops are the most important crops; while in resistant
economy condition, crops such as field crops, olives and palms are the most important
crops. Pticina and Yatskiv (2015) use AHP for developing the service quality index for
the urban public transport system. In decision making, efficiency and performance
evaluation plays an important role. Jablonsky (2015) apply AHP for efficiency analysis
of a general set of Government decision making units.

2.3 SWOT-AHP method

SWOT provides the basic framework that helps to perform an analysis for decision
making. AHP assists to carry out SWOT in a systematic way and provides a quantitative
measure of the weights of SWOT factors. By integrating SWOT with AHP, individual
SWOT factors can be analysed and rated quantitatively. This helps to determine the
intensity or importance of each factor. When policy makers use the SWOT-AHP method,
a more comprehensive decision making tool for effective strategic planning is obtained
than that by the use of the traditional SWOT method alone. Shrestha et al. (2004) analyse
the prospects and challenges for silvopasture adoption in south-central Florida using the
SWOT in combination with the AHP method. Data from the leaders who have an
extensive knowledge about silvopasture practices in south-central Florida are used for the
purpose of the study. Results reveal that strengths and opportunities for silvopasture
adoption outweigh its weaknesses and threats. Kahraman et al. (2007) prioritise
e-governance strategies in Turkey using the SWOT-AHP analysis. Arslan and Turan
(2009) identify the factors that affect marine causalities at the strait of Istanbul using
SWOT analysis and prioritised the factors using the AHP method. Wickramasinghe and
Takano (2009) use hybrid SWOT-AHP technique for strategic marketing planning for the
purpose of tourism revival in Sri Lanka. Results of this study indicate that proactive
communication strategy and isolation strategy with effective marketing promotional
strategy are the best strategies.
E-governance is facing challenges which have crucial effects on its performance.
Good strategies are required for e-governance implementation in order to overcome these
challenges. Alshomrani and Qamar (2012) analyse Saudi Arabia’s e-governance using
the SWOT technique and identify the intensities of SWOT factors using the AHP
technique. The results indicate that user-centric strategy and bridging digital divide
strategy, good communication strategy and citizen awareness strategy are the best
strategies in the order of preference. Gorener et al. (2012) determine significant factors
for a manufacturing firm by combining SWOT with AHP technique. Findings of this
study show that the ranking of SWOT group is maximum for strength followed by
262 M.N. Anish et al.

opportunity, weakness and threat. Seker and Ozgurler (2012) use SWOT analysis as a
method to determine strategies based on SWOT factors for a consumer electronic
company in Turkey.
Sharifipour and Mahmodi (2012) determine the vision, the mission and the objectives
of developing effective environmental management strategies of the eastern coasts of
Mazandaran using the SWOT-AHP technique. They opine that the provision for
environment management plan and formulation of the environmental strategies for
coastal regions are the most essential measures required for managing the coastal regions.
Stainback et al. (2012) investigate the perception of the Rwandan government officials,
the NGOs, and the extension specialists about small-holder agro-forestry adoption using
the SWOT-AHP technique. The results of the study indicate that small-holder
agro-forestry is viewed positively as a suitable strategy for Rwandan small-holder
farmers. AHP method is used to prioritise the factors that are determined from SWOT
analysis. On the basis of an extensive literature survey, Yuan et al. (2012) identify sixteen
SWOT factors for public housing through public-private partnership in China. After
identifying the factors, SWOT analysis is combined with AHP to determine the strategy
for the Chinese Government to develop public housing through public-private
partnership.
The review of the literature reveals that combining SWOT and AHP makes the
SWOT analysis more effective for decision making. There are no studies reported in the
literature on the application of SWOT-AHP in the medical tourism sector of Kerala.
Since medical tourism has emerged as a significant contributor to the Indian economy,
the present study focuses on the application of the SWOT-AHP method to the medical
tourism sector. This helps to identify the SWOT and prioritise these factors for
developing the strategies.

3 Salient features of SWOT analysis and hybrid SWOT-AHP method

The salient aspects of the SWOT analysis and the hybrid SWOT-AHP method are
discussed in this section. The first step in the present study consists of identifying the
factors of all the SWOT groups through literature review and through focus-group
interview with the experts in the medical tourism sector of Kerala. SWOT analysis
provides valuable information for strategic decision making. However, SWOT analysis is
a qualitative tool. AHP involves prioritisation of the SWOT groups and the factors of
each SWOT group. SWOT analysis combined with AHP provides an improved
application of the SWOT matrix.

3.1 SWOT analysis

Based on the literature review and the focus-group interview with experts, 21 effective
factors are identified and these factors are shown in Table 1.
The identified factors for SWOT in the medical tourism sector of Kerala act as a basic
skeleton for the study. Six factors are under strength group, four factors are under
weakness group, six factors are under opportunities group and five factors are under
threat group. As shown in Table 1, the factors of strength group include reputation of the
doctor, medical technologies, safety measures, hospitality, personalised services and
 SWOT-AHP analysis in medical tourism area of Kerala 263

communication ability. The deficiencies or weaknesses with respect to the internal factors
are accreditation, uniform standards for services, branding and pricing.
Table 1 SWOT factors in medical tourism sector of Kerala

Group Description Source

Strengths S1 Medical doctors of international fame Dawn and Pal (2011), Ansari
and repute. (2012), Badwe et al. (2012),
Izadi et al. (2012) and Rath
et al. (2015)
S2 Availability of latest medical Ansari (2012) and Izadi et al.
technologies. (2012)
S3 Providing safety measures. Padma (2013)
S4 Good hospitality. Tuhin and Majumder (1905)
S5 Personalised services. Ansari (2012)
S6 No language barrier. Tuhin and Majumder (1905) ,
Varkey and Bennet (2010),
Dawn and Pal (2011) and
Badwe et al. (2012)
Weakness W1 Lack of accredited hospitals. Varkey and Bennet (2010)
W2 Lack of uniform standards. Dawn and Pal (2011)
W3 Lack of branding. Varkey and Bennet (2010)
W4 Lack of uniform pricing policy. Ansari (2012)
Opportunities O1 Quality service at reduced cost. Rath et al. (2015), Varkey and
Bennet (2010) and Dawn and
Pal (2011)
O2 Low waiting time for the treatment. Varkey and Bennet (2010)
O3 Absence of insurance in many Varkey and Bennet (2010) and
countries force people to go to foreign Aniza et al. (2009)
countries.
O4 Government makes policies in favour Dawn and Pal (2011)
of medical tourism sector.
O5 Advances in information and Shanker (2008)
communication technology.
O6 Impact on related service sectors and Rath et al. (2015) and Tuhin
national economy. and Majumder (1905)
Threats T1 Strong competition from other Tuhin and Majumder (1905)
countries. and Varkey and Bennet (2010)
T2 Complex medical visa procedures. Izadi et al. (2012) and Dawn
and Pal (2011)
T3 Hard competition standards. Cinar et al. (2013)
T4 No reimbursement in home country Varkey and Bennet (2010)
for treatment undergone in a foreign
country.
T5 Doubt about the diseases such as Varkey and Bennet (2010)
malaria, H5N1, dengue, etc.
264 M.N. Anish et al.

In a similar manner, the factors consisting of opportunities and threats are also identified.
The factors that constitute opportunities are quality service with reduced cost, low
waiting time for treatment, insurance policies in foreign countries, policies of Indian
Government, information and communication technology and general economy. The
factors such as competition, medical visa procedure, medical standards, reimbursement
policies of the countries and prevailing common diseases are the challenges in medical
tourism sector and hence these factors form the threats.

3.2 Hybrid SWOT-AHP analysis

SWOT exists within the operational environment of organisations. Under each of the
SWOT group, factors also exist. The experts express their preferences about the groups
and factors based on their knowledge and expertise. The collective opinion is used to
obtain the relative importance of different factors. AHP is used to prioritise the SWOT
groups and the factors in each SWOT group. After conducting SWOT-AHP analysis,
appropriate strategies can be framed. The hierarchical structure of the hybrid
SWOT-AHP is shown in Figure 1.

Figure 1 Hierarchy structure

The pair-wise comparison of the SWOT groups and the factors in each SWOT group are
determined on the basis of expert preferences. The pair-wise comparison matrix is
normalised and the relative weights of the SWOT groups and of the factors in each
SWOT group are computed. Finally, the consistency of the pair-wise comparison
matrices is examined to ensure that the judgements/evaluations of the experts are
sufficiently consistent. The details of the pair-wise comparison of the SWOT groups and
that of the factors in each SWOT group are presented in the following sub-section.

3.2.1 Paired comparisons of SWOT groups and factors of SWOT groups using
AHP
In the present study, SWOT groups and factors of SWOT groups are prioritised based on
AHP. Initially, the prioritisation procedure involves conducting a pair-wise comparison
of the four SWOT groups. This pair-wise comparison matrix is formed based on expert
opinions. Ten experts in the medical tourism sector were requested to provide their
 SWOT-AHP analysis in medical tourism area of Kerala 265

judgement/evaluation by performing pair-wise comparison of the SWOT groups using

the nine point scale of Saaty (1980). Table 2 provides the structure of the fundamental
scale.
Table 2 Fundamental scale for pair-wise comparison

Intensity of importance
Definition Explanation
on an absolute scale
1 Equal importance Two activities contribute equally to
the objective.
3 Moderate importance of one Experience and judgement slightly
over another favour one activity over another.
5 Essential or strong Experience and judgement strongly
importance favour one activity over another.
7 Very strong importance An activity is favoured very strongly
over another; its dominance
demonstrated in practice.
9 Extreme importance The evidence favouring one activity
over another is of the highest
possible order of affirmation.
2, 4, 6, 8 Intermediate values Intermediate values between two
adjacent judgements.

Pair-wise comparisons of SWOT groups and factors of SWOT groups are presented in a
matrix form as follows.
⎡ a11 α12 " α1n ⎤
⎢α α 22 " α 2 n ⎥⎥
=⎢
21
A[i , j ]
⎢" " " " ⎥
⎢ ⎥
⎣α n1 α n2 α nn ⎦
Elements of the matrix indicate the relative importance of the ith element over jth element.
According to Saaty (1980),
Aw = λmax w
where
λmax Largest eigen value of matrix A.
w Associated eigen vector or vector of weight of the comparison matrix.
⎡ w1 ⎤
w = ⎢⎢ w2 ⎥⎥

⎢⎣ w n ⎥⎦

λmax ≥ n, where n is the order of the matrix.

Prioritisation procedure for SWOT groups is followed by the prioritisation procedure
for the six factors of the strength group, four factors of the weakness group, six factors of
the opportunities group and five factors of the threat group. AHP helps to derive the
relative weights for the above mentioned factors.
266 M.N. Anish et al.

3.2.2 Checking for consistency

A minimal consistency is required to obtain meaningful priorities. Thus, it is required to
check the consistency of the pair-wise comparisons. According to Saaty (1980),
( λmax − n )
CI =
(n − 1)

where CI = consistency index.

CI
According to Saaty (1980), consistency ratio (CR) is defined as . If CR is ≤ 0.10,
RI
the degree of consistency is considered to be satisfactory. In the above equation,
RI = random index. Table 3 provides RI values for different number of attributes
considered in the pair-wise comparison process (Gorener et al., 2012).
Table 3 Random index

Number of 1 2 3 4 5 6 7 8 9 10
attributes, n
Random - - 0.58 0.90 1.12 1.24 1.32 1.41 1.45 1.49
index, RI

Consistency implies rational judgement on the part of the decision maker. A pair-wise
comparison matrix with two attributes is always consistent. This implies that when the
number of attributes is one or two, there is no need for checking consistency. Hence, in
Table 3, the entry under n = 1 and n = 2 is made as -.

4 Estimation of weights using the SWOT-AHP method

A questionnaire was prepared for the pair-wise comparisons between the SWOT
groups/factors of each group. This questionnaire was used to obtain the judgements of the
experts in the medical tourism sector. A sample questionnaire to compare two factors of
strength group is shown in Figure 2.

Figure 2 Comparison of two factors

Compare the strengths and mark appropriate level of importance

More More
Personalized
9 8 7 6 5 5 4 3 2 1 2 3 4 5 6 7 8 9 No language barrier
services

Initially, pair-wise comparison matrix is required for the elements in the first level in the
hierarchy. Hence, a pair-wise comparison among the SWOT groups is carried out.
According to Saaty (2008), individual experts may not wish to combine their judgements,
but only their final outcomes obtained from their hierarchy.
 SWOT-AHP analysis in medical tourism area of Kerala 267

Pair-wise comparison about each group or factor by the expert helps to obtain the
comparison matrix. After obtaining the comparison matrix from an individual expert, in
order to determine the final outcome of the single expert, geometric mean of each row of
comparison matrix is calculated. This results in a column vector. This column vector is
normalised by dividing each element of the column vector by the sum of all the elements
in the column vector. This method is known as row geometric mean method (RGMM).
This procedure is carried out for all the ten experts. The priority vector obtained for the
first expert is given as the first column that of the second expert is given as the second
column and accordingly in the same order as shown in the matrix presented below.
Normalised priorities of ten experts

⎡ 0.45 0.45 0.38 0.43 0.42 0.48 0.39 0.44 0.43 0.44 ⎤
⎢0.12 0.11 0.11 0.09 0.12 0.10 0.14 0.12 0.14 0.09 ⎥⎥
=⎢
⎢0.29 0.29 0.33 0.31 0.27 0.28 0.30 0.30 0.25 0.31⎥
⎢ ⎥
⎣ 0.15 0.16 0.18 0.16 0.18 0.14 0.18 0.14 0.19 0.16 ⎦

Using the above matrix, geometric mean of the normalised priorities of the SWOT groups
for the experts is calculated according to the equation (1) shown below.
K
Z iG = ∏ [ Z (k )]
k =1
i (1)

where

k represents the number of decision maker

Zi(k) priority of the ith alternative for the kth decision maker

Z iG aggregated group priority value.

The geometric mean obtained according to the above calculation provides a column
vector. The first element of the column vector indicates weight of strength group, second
element indicates weight of weakness group, third element indicates weight of
opportunity group and fourth element indicates weight of threat group. The weight of
SWOT group thus obtained is as follows.

⎡ 0.42 ⎤
⎢ 0.12 ⎥
Weight of SWOT groups = ⎢ ⎥
⎢ 0.29 ⎥
⎢ ⎥
⎣ 0.17 ⎦
The same procedure is adopted to find the weight of all the factors of SWOT groups. The
normalised priorities for the six factors of strength group for the ten experts are given in
the following matrix.
Normalised priorities of ten experts for strength group
268 M.N. Anish et al.

⎡0.33 0.35 0.27 0.35 0.35 0.33 0.35 0.39 0.38 0.31 ⎤
⎢0.25 0.24 0.30 0.28 0.27 0.22 0.28 0.24 0.23 0.22 ⎥⎥
⎢
⎢0.14 0.14 0.11 0.12 0.14 0.14 0.12 0.10 0.10 0.14 ⎥
=⎢ ⎥
⎢0.09 0.09 0.12 0.07 0.08 0.09 0.07 0.08 0.07 0.09 ⎥
⎢0.11 0.12 0.13 0.11 0.09 0.13 0.11 0.12 0.12 0.13 ⎥
⎢ ⎥
⎣⎢0.08 0.06 0.08 0.07 0.06 0.09 0.07 0.08 0.09 0.10 ⎦⎥

The normalised priorities for the four factors of weakness group for the ten experts are
given in the following matrix.
Normalised priorities of ten experts for weakness group
⎡0.48 0.45 0.45 0.36 0.48 0.44 0.38 0.39 0.45 0.44 ⎤
⎢ 0.11 0.11 0.12 0.10 0.10 0.09 0.11 0.14 0.11 0.12 ⎥⎥
=⎢
⎢ 0.23 0.28 0.29 0.37 0.27 0.31 0.33 0.30 0.29 0.30 ⎥
⎢ ⎥
⎣0.18 0.16 0.15 0.16 0.14 0.16 0.19 0.17 0.16 0.14 ⎦

The normalised priorities for the six factors of opportunity group for the ten experts are
given in the following matrix.
Normalised priorities of ten experts for opportunity group
⎡ 0.35 0.33 0.31 0.31 0.33 0.38 0.34 0.33⎤
0.34 0.35
⎢ 0.28 0.22 0.22 0.23 0.21 0.23 0.22 0.26 ⎥⎥
0.28 0.28
⎢
⎢ 0.12 0.14 0.14 0.14 0.13 0.10 0.13 0.12 ⎥
0.12 0.12
=⎢ ⎥
⎢0.07 0.09 0.11 0.10 0.11 0.07 0.10 0.07
0.09 ⎥ 0.07
⎢ 0.11 0.13 0.13 0.13 0.13 0.13 0.11 0.12 0.11 0.12 ⎥
⎢ ⎥
⎣⎢0.07 0.08 0.09 0.09 0.09 0.10 0.10 0.07 0.07 0.09 ⎦⎥

The normalised priorities for the five factors of threat group for the ten experts are given
in the following matrix.
Normalised priorities of ten experts for threat group

⎡0.34 0.36 0.36 0.34 0.38 0.38 0.34 0.32 0.38 0.36 ⎤
⎢0.26 0.27 0.25 0.28 0.26 0.23 0.26 0.24 0.26 0.23⎥⎥
⎢
= ⎢0.19 0.16 0.20 0.20 0.16 0.20 0.19 0.23 0.17 0.20 ⎥
⎢ ⎥
⎢ 0.08 0.09 0.07 0.06 0.07 0.08 0.08 0.09 0.07 0.08 ⎥
⎢⎣0.14 0.12 0.12 0.13 0.14 0.12 0.14 0.13 0.13 0.13⎥⎦

The weight of the individual factors of strength group is calculated according to the
equation (1). The weight of the first factor of strength group is given as the first element
of the column vector, weight of the second factor is the second element and similarly for
the other factors also. The weight of the six factors of strength group is given as the
following vector.
 SWOT-AHP analysis in medical tourism area of Kerala 269

⎡ 0.34 ⎤
⎢ 0.25 ⎥
⎢ ⎥
⎢ 0.12 ⎥
Weight of strength factors = ⎢ ⎥
⎢ 0.09 ⎥
⎢ 0.12 ⎥
⎢ ⎥
⎣⎢ 0.08 ⎦⎥
The weight of the individual factors of weakness, opportunity and threat groups are also
calculated in the same manner. The weight of the four factors of weakness group is given
as the following vector.
⎡ 0.43 ⎤
⎢ 0.11 ⎥
Weight of weakness factors = ⎢ ⎥
⎢ 0.30 ⎥
⎢ ⎥
⎣ 0.16 ⎦
The weight of the six factors of opportunity group is given as the following vector.
⎡ 0.33 ⎤
⎢ 0.24 ⎥
⎢ ⎥
⎢ 0.13 ⎥
Weight of opportunity factors = ⎢ ⎥
⎢ 0.09 ⎥
⎢ 0.12 ⎥
⎢ ⎥
⎣⎢ 0.09 ⎦⎥
The weight of the five factors of threat group is given as the following vector.

⎡ 0.36 ⎤
⎢ 0.25 ⎥
⎢ ⎥
Weight of threat factors = ⎢ 0.18 ⎥
⎢ ⎥
⎢ 0.08 ⎥
⎢⎣ 0.13 ⎥⎦

4.1 Checking for consistency

The CR is calculated for the SWOT groups and also for the factors of SWOT groups.
Since the CRs obtained are less than 0.10 in all the cases, it is concluded that the
comparisons are consistent. The local and the global priorities of the entire SWOT factors
are calculated. Local weight scores provide the level of priority of all factors with respect
to each SWOT group. Overall weight scores are calculated by multiplying the local
weight score of the factor within the SWOT group with the group weight score. The
results thus obtained are shown in Table 4. The greatest weight score within each SWOT
group is shown in italics letters.
270 M.N. Anish et al.

Table 4 SWOT factors and weights

Group and
Description Local weight Global weight
weight
Strength (0.42) S1 Medical doctors of international 0.34 0.14
fame and repute.
S2 Availability of latest medical 0.25 0.11
technologies.
S3 Providing safety measures. 0.12 0.05
S4 Good hospitality. 0.09 0.04
S5 Personalised services. 0.12 0.05
S6 No language barrier. 0.08 0.03
Weakness (0.12) W1 Lack of accredited hospitals. 0.43 0.05
W2 Lack of uniform standards. 0.11 0.02
W3 Lack of branding. 0.30 0.03
W4 Lack of uniform pricing policy. 0.16 0.02
Opportunity O1 Quality service at reduced cost. 0.33 0.10
(0.29)
O2 Low waiting time for the 0.24 0.07
treatment.
O3 Absence of insurance in many 0.13 0.04
countries force people to go to
foreign countries.
O4 Government makes policies in 0.09 0.03
favour of medical tourism
sector.
O5 Advances in information and 0.12 0.03
communication technology.
O6 Impact on related service sectors 0.09 0.02
and national economy.
Threat (0.17) T1 Strong competition from other 0.36 0.06
countries.
T2 Complex medical visa 0.25 0.04
procedures.
T3 Hard competition standards. 0.18 0.03
T4 No reimbursement in home 0.08 0.02
country for treatment undergone
in a foreign country.
T5 Doubt about the diseases such as 0.13 0.02
malaria, H5N1, dengue, etc.

The global weights of all SWOT factors are shown in Figure 3.

 SWOT-AHP analysis in medical tourism area of Kerala 271

Figure 3 Global weight of SWOT factors in medical tourism sector of Kerala (see online version
for colours)

5 Analysis of results and managerial implications

Patients are forced to move from their home country for better treatment prospects either
due to the over-priced treatment structures or due to the unavailability of suitable
treatment options in their home country or due to both. The unavailability of experienced
doctors and/or the unavailability of latest technologies and facilities in the medical field
in their home country are also some of the other concerns. Kerala has a major role in
medical tourism sector.
By using SWOT analysis, the present study identifies the strengths, weaknesses,
opportunities and threats in the medical tourism sector of Kerala. By integrating SWOT
factors with the AHP technique, the weights of SWOT groups and different factors of
SWOT groups are identified. Priority obtained for these factors helps to develop
strategies for this sector and the strategies enable to concentrate on the important SWOT
factors. The highlights of this research study are as follows:
1 Considering factors of strengths (S1, S2, S3, S5) and factors of opportunities
(O1 and O2)
Available strength can be used to utilise the opportunities present. Availability of
reputed doctors, latest medical technologies, safety measures, personalised services
to the international patients, etc., can be utilised to attract international patients to
Kerala, so that they receive quality service at reduced cost and with less waiting
time.
2 Considering factors of strengths (S1, S2, S3, S5) and factors of threats (T1 and T2)
A strong competition exists from other countries and getting medical VISA is not
easy. The effect of these hurdles can be reduced to a certain extent using the
advantages of medical tourism sector of Kerala such as availability of reputed
doctors and latest medical technologies, safety measures, personalised services, etc.,
in the medical tourism sector of Kerala.
272 M.N. Anish et al.

3 Considering factors of weaknesses (W1, W3) and factors of opportunities (O1, O2)
Hurdles like the lack of accredited and branded/reputed hospitals exist in the medical
tourism sector of Kerala. These hurdles can be avoided to a certain extent by utilising
the opportunities like providing good quality service at low cost and reducing the
waiting time to get the treatment.
4 Considering factors of weaknesses (W1, W3) and factors of threats (T1, T2)
Weaknesses of the medical tourism sector should not connect to threats. A possible
solution could be increasing the number of accredited and branded/reputed hospitals
to attract international patients, since hurdles like competition from other countries
and difficulties to get medical VISA exist. Getting the treatment in an accredited and
branded/reputed hospital will attract international patients.
The factors and their relative weights are identified with the hybrid SWOT-AHP method.
Concentrating on these factors helps the medical tourism sector of Kerala to achieve a
pioneer position. The management and the Government can concentrate on the identified
key areas. Thus, this study provides valuable insights to the medical tourism sector of
Kerala.

6 Conclusions

International patients travel to other countries for getting good quality treatment at a
comparatively lower cost. Some of the treatments (for example, organ transplantations)
are not even available in their home country due to legal aspects. Availability of talented
doctors and medical technologies are some of the other reasons for patients in a
home-country moving to other countries. Identifying the SWOT is important in medical
tourism sector. SWOT analysis with the help of literature review and discussions with the
experts of the field is used for identifying the key factors of medical tourism sector. AHP
helps to identify the weight or relative importance of the SWOT groups and also of the
factors of SWOT groups. Pair-wise comparisons help to analyse the situation more
precisely than the standard SWOT method. Twenty one items are identified from SWOT
groups. This includes six factors from strength group, four factors from weakness group,
six factors from opportunity group and five factors from threat group.
Ranking of SWOT groups is done using AHP and it is found that strength is the most
important group. Priority for strength is obtained as 42%, for weakness 12%, for
opportunities 29% and for threats 17%. Strategic factors and their weights are determined
by combining the SWOT with the AHP technique. The most crucial SWOT factors of
SWOT groups are identified using the hybrid SWOT-AHP method. Strength group
emerges as the most important group among all the SWOT groups.
The most important factor from all the SWOT groups is ‘medical doctors of
international fame and repute’ which belongs to the strength group. The important factor
from the weakness group is identified as ‘lack of accredited hospitals’. From the
opportunity group, the important factor is ‘quality service at reduced cost’ and from the
threat group, the important factor is ‘strong competition from other countries’. The
combined use of SWOT with AHP helps to support strategic decision making processes.
Based on the findings of the study, the management can concentrate on the following
aspects.
 SWOT-AHP analysis in medical tourism area of Kerala 273

1 Identify the strengths of the medical tourism sector that help to minimise the effects
of external threats.
2 Concentrate on internal weaknesses that help to reduce the effects of external threats.
3 Focus on strengths of the medical tourism sector to utilise the external opportunities
available.
4 Utilise the external opportunities to reduce the internal weaknesses of the medical
tourism sector.
A limited number of experts are considered in the present study. Future study can be
conducted with the participation of more number of experts. A similar study can be
carried out in the medical tourism sector of each of the other states in India. The results
obtained from such studies can be consolidated to determine the significant SWOT
factors in the medical tourism sector of the nation.

Acknowledgements

The authors express their sincere thanks to all the experts who have provided valuable
judgements for the present study. The authors express their sincere thanks to the editor
and the reviewers for their valuable comments.

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