Medical Tourism Destination Research Articles

The Effects of Dynamic Link Between Sustainable Development Goals (SDGs) And Medical Tourism: A Study of Medical Tourist Intention in Malaysia and Indonesia

Purpose: The study attempts to examine the behavioural intention of the medical tourist in choosing Malaysia and Indonesia as medical tourism destination. Theoretical framework: There are three determinants (behavior intention, perceived destination image, perceive value and trust as mediator are included in the current study. The theory of Planned Behavior shall form the basis of the conceptual framework for this study. Design/methodology/approach: This descriptive study aims to investigate the phenomenon of medical tourism through questionnaires. It assesses measurement scales for reliability and validity, and explores relationships between perceived destination image, perceived value, and behavioral intention, ultimately seeking to generalize findings to the broader population. Findings: This study illustrates that all the variables are vital in influencing Malaysia and Indonesia as destination for medical tourism. Based on the theory of Planned Behavior have form the basis of the variables. Hence, all antecedent factors need to be taken into consideration which will influence the medical tourists. Research, Practical & Social implications: Future research should focus on the comparative discussion for public hospitals and private hospitals in order to improve Malaysia’s and Indonesia’s performance in competing with other country as well as building trust among the medical tourists so that we (Malaysia and Indonesia) will be their first choice for medical tourism. Originality/value: By understanding the relationships between behavioral intention, destination image, perceived value and trust, the destination country would have a better idea how to and improve their marketing efforts in attracting as many medical tourists as possible.

Theatre and the Development of Spa Tourism in Eighteenth-Century Tralee

On Saturday, 6 March 1756, Shakespeare’s 1 Henry IV was staged in the Assembly Room on Castle Street in the town of Tralee in county Kerry. Far from being a one-off, this heralded the start of a season of theatrical performances by a troupe of actors who had travelled from Dublin. There were thirty nights of performances between the opening on 6 March and the final entertainment on Monday 10 May 1756. Why were Shakespeare’s and other plays being performed in a small town on Ireland’s south-west Atlantic coast, and what might have been the social, cultural, and commercial circumstances of their performance? It is suggested that the plays may have been staged as part of an effort on the part of the town’s proprietor and local landowner, Sir Thomas Denny, to develop Tralee as a destination for medical tourism and spa sociability.

뷰티의료관광의 기대, 지각된 가치 및 행동의도: DSC (관광목적지-자아일치도)의 조절효과를 중심으로

Purpose: In-depth research has been conducted, focusing on the beauty as one of the pursuits of tourists, particularly in the context of cosmetic surgery tourism. Beauty medical tourism should provide not only excellent medical services but also tourism programs at destination where enhance effective treatment. Therefore, this research argued the significance of destination brand management by verifying that tourist’s self-congruity is related with variables such as expectation, perceived values and behavioral intention. Methods: Based on the Meaning Transfer Theory (MTT) and the Destination Self-Congruity (DSC) theory, research model was designed. A survey was conducted targeting Chinese women tourists who share a substantial portion of the South Korean beauty medical tourism market. Total 340 valid samples were collected for a month from April in 2023. Using SPSS 18.0 and Smart PLS 4.0 packages, measurement model’s reliability and validity were tested. Structure model’s model fit and path analysis were conducted. Results: The empirical analysis revealed several significant findings: Expectation of beauty medical tourism had a significant impact on perceived values (Hypothesis 1). Perceived values of medical tourism significantly influenced behavioral intention (Hypothesis 2). Beauty medical tourism DSC had significant moderating effects on perceived values, and behavioral intention, partially. (Hypothesis 3). In specific, DSC have moderating effect, leading external perceived value to behavioral intention. Conclusion: To induce potential medical tourists to visit, how to brand the beauty of DSC, or medical tourism destinations where medical services are provided, and how to match this with potential tourists self-congruity are the key to realizing beauty medical tourism.

Medical Tourism Management

Medical tourism, the practice of traveling abroad for medical treatment, has gained substantial attention in recent years due to its implications for healthcare delivery and tourism industry dynamics. This paper investigates the management strategies employed in medical tourism destinations, focusing on enhancing healthcare services and tourism competitiveness. Utilizing secondary data from scholarly articles, reports, and industry publications, the research synthesizes existing knowledge on medical tourism management frameworks, destination competitiveness factors, patient experiences, and healthcare quality metrics. The study employs a qualitative analysis approach to distill key insights and patterns from the literature, shedding light on effective management practices and their impact on patient outcomes and destination attractiveness. Findings reveal the importance of strategic planning, collaboration between healthcare providers and tourism stakeholders, quality assurance mechanisms, and marketing strategies in optimizing medical tourism experiences. The paper discusses implications for policy development, industry regulations, and sustainable growth strategies in medical tourism destinations. By leveraging secondary data sources, this research contributes to a comprehensive understanding of medical tourism management dynamics, offering practical insights for healthcare providers, policymakers, and tourism professionals navigating this evolving landscape. Keywords- Medical tourism, Management strategies, Destination competitiveness, Healthcare quality

Sustainable medical tourism in the global competitive environment: The case of Cyprus.

The aim of this study is to examine the perceptions of Cypriot medical tourism experts regarding the phenomenon of medical tourism, as well as to emphasise the benefits and opportunities for Cyprus to become a highly competitive global healthcare destination. A Delphi study was conducted in Cyprus, with the participation of 20 experts in the field of medical tourism. At first, 20 experts took part in semi-structured interviews. Based on their feedback provided during that phase, a structured questionnaire was drawn up and completed, addressing a wide variety of medical tourism-related issues, such as benefits and losses from the development of medical tourism in Cyprus, advantages and disadvantages of Cyprus in attracting international patients, the key elements of a medium- to long-term strategic plan for the development of medical tourism in Cyprus, the role of the public and private sector and the importance of international accreditation of private and public hospitals. Cyprus appears to have some very favourable qualities when it comes to its listing as a competitive destination for medical travellers. Undeniably, the growth of medical tourism improves all sectors of the economy and society, but the healthcare industry is the one that benefits most. On the opposite end, medical tourism could potentially impact the access of local people to healthcare services. No clear answers were given by the expert respondents on the need for international accreditation of healthcare providers in Cyprus. The competent authorities should promote Cyprus to international markets as a medical tourism destination of choice, upgrading the quality of healthcare services it provides having due regard in parallel to any potential impacts to the access of local population to the healthcare system.

A Comparative Study of Karnataka's Ayurvedic Medical Tourism Industry: North vs. South

Karnataka is a state in India with a rich cultural heritage and a diverse range of traditional practices, including Ayurveda, the ancient Indian system of medicine. The increasing popularity of Ayurveda among tourists has made it a significant contributor to the state's economy, particularly in the form of Ayurvedic medical tourism. This research paper provides a comprehensive analysis of the condition of Karnataka's Ayurvedic medical tourism industry, with a comparative study of North and South Karnataka. According to a report by the Karnataka State Tourism Development Corporation (KSTDC), the state's tourism sector contributed 6.5% to its GDP in 2018, generating a revenue of INR 45,000 crore. The Ayurvedic medical tourism sector played a crucial role in this growth, with a contribution of INR 400 crore in 2018. The industry is expected to grow further in the coming years, with estimates suggesting a growth rate of 20-25% annually. North Karnataka and South Karnataka have different potentials and challenges for developing the Ayurvedic medical tourism industry. North Karnataka is less developed compared to South Karnataka and has the potential to develop Ayurvedic medical tourism. North Karnataka has a rich history and cultural heritage, with several ancient temples, forts, and palaces, which can attract tourists. North Karnataka has several Ayurvedic medical tourism centers that offer traditional Ayurvedic treatments and therapies. On the other hand, South Karnataka is more advanced and has already established Ayurvedic medical tourism centers. South Karnataka has several cultural and historical sites, such as the Mysore Palace and the Srirangapatna Fort, waterfalls, high hills in coorge, chikkamagalore, uttarakannada, Udupi, Mangalore, shimogga etc.which can attract tourists. The region also has a higher concentration of wellness resorts and luxury hotels compared to North Karnataka. However, South Karnataka faces challenges such as high competition and the need to maintain quality standards to retain its position as a popular destination for Ayurvedic medical tourism. Karnataka's Ayurvedic medical tourism industry has several opportunities for growth. The increasing popularity of Ayurveda among tourists, coupled with the state's rich cultural heritage and natural beauty, offers tremendous potential for the industry. The state government has also taken initiatives to promote Ayurvedic medical tourism, However, the industry also faces several challenges. One of the major challenges is the lack of standardization and regulation in the Ayurvedic medical tourism sector. The industry needs to maintain quality standards to retain its position as a popular destination for medical tourists. Another challenge is the high competition within the industry, with several other states in India promoting Ayurvedic medical tourism. Karnataka needs to develop unique offerings and experiences to attract tourists and differentiate itself from its competitors. In conclusion, Karnataka's Ayurvedic medical tourism industry has a significant economic impact on the state's economy, and both North and South Karnataka have different potentials and challenges for developing the industry. While the industry has several opportunities for growth, it also faces challenges such as lack of standardization and high competition. The state government's initiatives to promote Ayurvedic medical tourism, coupled with efforts by the industry to maintain quality standards and offer unique experiences, can help the industry realize its potential and contribute further to the state's economy.

Health tourism in Malaysia: understanding the drivers of satisfaction and revisit intention

ABSTRACT Medical tourism is a dynamic industry that seeks to improve satisfaction and foster loyalty among Arab medical tourists. This study delves into the complex experience of medical tourism among Arab patients in Malaysia by using an integrated analytical framework that examines the combined effects of quality perception and recovery experience on tourists’ satisfaction and intentions to revisit. Utilising a cross-sectional design with purposive sampling, the study collected responses from 432 Arab patients, employing Partial Least Squares Structural Equation Modelling (PLS-SEM) and Necessary Conditions Analysis (NCA) to analyze the data. The findings reveal that perceived quality, especially in healthcare services and post-treatment care, significantly enhances tourist satisfaction, which directly influences their intentions to revisit. Additionally, trust emerged as a critical factor that not only strengthens the relationship between satisfaction and revisit intentions but also acts as a necessary condition for achieving high satisfaction levels. This research contributes to tourism literature by detailing the specific pathways through which service quality and recovery experience impact tourist satisfaction and revisit intentions. It provides practical insights for medical tourism providers to optimise service delivery and trust-building strategies, thereby enhancing Malaysia's reputation as a premier medical tourism destination.

Medical tourism destination image: Scale development

AbstractIn response to heightened competition among destinations vying for medical tourists, these destinations have prioritized improving their image. Although several scales exist to assess destination images, there is a scarcity of scales specifically tailored to measure the image of medical tourism destinations. To address this gap, a thorough scale development process was employed, resulting in the creation of a second‐order model known as the medical tourism destination image scale. This scale explores four dimensions: quality of doctors and hospitals, ease of travel and safety, variety of treatment, and communication. The findings underscore the significant potential for marketers and policymakers to enhance the attractiveness of medical tourism destinations.

Developing 'Brand India' as a premier destination for medical and wellness tourism: PESTEL analysis and implementation framework

Developing 'Brand India' as a premier destination for medical and wellness tourism: PESTEL analysis and implementation framework

Impact of health tourism visitor experiences on behavioral intention

PurposeThis paper examines the factors that influence behavioral intention in the context of medical tourism in Türkiye. With the growing popularity of Türkiye as a destination for medical tourism, it is essential to understand the key determinants influencing individuals’ intention to engage in medical tourism activities.Design/methodology/approachThis study used the Extended Theory of Planned Behavior (E-PBT) variables, which include attitude, subjective norm and perceived behavioral control, to measure their influence on behavioral intention. In addition, a customer experience scale was used to assess the influence of dimensions such as education, entertainment, aesthetics and escapism on behavioral intention. The research instrument was validated by expert review, and data were collected using purposive sampling. A total of 420 surveys were deemed suitable for analysis.FindingsThe path analysis revealed that attitudes and perceived behavioral control positively impacted behavioral intention within the domain of medical tourism in Türkiye. Conversely, subjective norms did not have a significant positive effect on behavioral intention. Furthermore, it was observed that the dimensions of entertainment, escape and aesthetics positively affected behavioral intention. However, education and aesthetics did not significantly influence behavioral intentions.Practical implicationsThe results of this paper have practical implications for marketers and policymakers in the medical tourism industry in Türkiye. Understanding the factors that drive individuals’ behavioral intentions can assist in developing effective marketing strategies to attract and serve potential medical tourists. Medical tourism providers can enhance their services by optimizing attitudes and perceived behavioral control while emphasizing entertainment and escapism for their clientele.Originality/valueThis research focuses on uncovering factors influencing individuals’ behavioral intentions in medical tourism in Türkiye. Using the E-PBT framework and exploring the dimensions of the customer experience scale, this study aimed to understand the driving forces behind individuals’ decisions to engage in medical tourism.

Medical tourism of Indian diaspora “back home”

Migration, diaspora, tourism, and health have emerged as prime research interests among social scientists. Interdisciplinary studies are being conducted on the interface of two or more of these domains analysing complex social mobility patterns, such as medical tourism, diaspora tourism, diasporic medical tourism and their like. Among these, medical tourism has emerged as a new form of transnational movement. Within this premise, diasporic dimension of medical travel has amassed substantial importance in contemporary times. These ethnic communities contribute to their homeland in form of investment, philanthropy, and development through healthcare production and consumption. This phenomenon is more prominent in India which is among the top medical tourism destinations and also holds the largest diaspora in the world. Indian government has formulated policies for attracting diasporas back home and also for developing the medical tourism potential of the country. However, there is need to merge the initiatives operational in these two different fields at ground level to obtain maximum benefit. At present, no study gives a nuanced account integrating these two disparate phenomena. Therefore, based on extensive literature review, the paper will seek to integrate the dimensions of medical tourism and diaspora tourism and thus, underline the phenomenon of medical tourism by Indian diaspora at their homeland. The systematic review pointed a large gap in academia within the domain of diasporic medical tourism in Indian context. Research situated around this domain is highly solicited as such studies will contribute substantially to the discourse of diaspora for development.

MEDICAL TOURISM IN THAILAND: QUALIFIED HEALTHCARE OR JUST AN OTHER BUSINESS STRATEGY AND MARKETING

This research paper examines the growing popularity of the medical tourism industry in Thailand, analyzing whether it is an affordable, world-class healthcare system or just another business strategy to attract tourists. This study, by focusing on various areas of Thai healthcare, including their cost structure, quality, overall professionalism, infrastructure, sheds light on the findings collected from primary and secondary sources about healthcare services in Thailand. This study has used a mixed method of data analysis with a combination of qualitative information obtained from healthcare professionals with quantitative data collected through surveying domestic and foreign tourists who have already used the healthcare services in Thailand. The results show that medical tourism in Thailand is not just affordable, but also meets international accreditation standards and has been able to establish a reputation in specific medical areas with complexities for example Sex Reassignment Surgery (SRS). The research also reveals the challenges faced by medical tourists due to language barriers, causing major concerns and serious misconceptions. While Thailand has established itself as a prominent medical tourism destination for individuals seeking medical treatment from nearby countries as well as patients from other distant continents. The research recognizes the need for collaboration between healthcare providers, policymakers, and the tourism sector to improve the overall medical tourism experience, finding better marketing strategies and working on existing issues, which can improve the sector and create a better experience.

Ayurveda is on the Way to Open the Golden Door of Indian Tourism through Panchakarma - A Review

ABSTRACT Over the years, Ayurveda, the science of healing and regeneration, has become increasingly popular throughout the world. Numerous Ayurvedic centres are expanding nowadays, as they are one of the primary tourist attractions in the southern region. India is becoming a popular destination for medical tourism due to a number of draw factors, including easy accessibility, affordable and high-quality medical care, beautiful vacation spots, etc. The best place is in South India, which is also the nation's centre of health. The boundaries and opportunities of Ayurvedic tourism have undoubtedly expanded with the recognition of Ayurvedic healing on a national and worldwide level. With any fortunate, India will be the world's top choice for high-quality medical facilities within the next several years. Ayurveda was supposedly bestowed upon humanity by the gods to enable us to live long, healthy lives free from illness. Nearly every tribe in India swiftly embraced ayurveda, and it soon started to spread to nations like Afghanistan, China, and Iran. Panchakarma can provide a long-lasting or permanent treatment for multi-system disruptions. Panchakarma is becoming a vital component of medical travel. Therefore, the government ought to actively support the growth of Panchakarma travel. This review discusses the many facets of ayurvedic travel to India, including Panchakarma, its development, and current trends. Keywords-Ayurveda, Tourism, Panchakarma, health .

Factors Influencing Domestic Tourist to Visit Bali as a Medical Tourism Destination: A Preliminary Investigation

The objective of this study was to examine the impact of destination image, destination image, perceived value of medical costs, and perceived value of medical facilities and services on the intention to visit Bali as a medical tourism destination. The research used quantitative methodology, employing a survey method. The population consisted of all of domestic tourists who visited Bali. The sample was 87 domestic tourists who came to Bali for medical tourism purposes. The research findings indicate that destination image, perceived value of medical costs, and perceived value of medical facilities and services have an impact on intention to visit Bali for medical tourism. However, the perception of Bali as a destination did not have any impact on tourists' intention to visit for medical tourism purposes. These findings provide both theoretical and practical implication. A collaborative effort involving several parties is necessary to enhance the branding and promotion of medical tourism.

Perception of medical tourism image from the perspective of healthcare professionals: The case of Turkey

The study aims to reveal Türkiye’s medical tourism destination image and its determinants from the perspective of healthcare professionals. The cross-sectional study population consists of healthcare professionals working in public hospitals in Türkiye (N=1.142.469). The research data were collected using a questionnaire consisting of two parts. The first part of the questionnaire consisted of statements aiming to reveal the socio-demographic characteristics of the participants. The “medical tourism image scale” was used in the second part of the questionnaire. The study data were collected online between July 1, 2022, and March 31, 2023. Of the participants, 64.9% were female, 58.1% were married, 37.7% were between the ages of 18-29, and 31.7% were physicians. 76.7% of the participants chose their profession willingly, 80.2% were dissatisfied with their lives in general, 23.9% were working in the Black Sea Region, and 56.9% stated that economic instability was the biggest obstacle to medical tourism. As a result of the study, the total score on the medical tourism scale was 94.270±12.751. According to the results of the correlation analysis, there was a relationship between service quality, safety and security, cost, tourism opportunities, hygiene, and accessibility (p<0.001). Türkiye’s medical tourism destination image is high, according to healthcare professionals. However, healthcare professionals think that economic instability is the biggest obstacle to medical tourism. The most important conclusion of the study is that service quality, safety and security, cost, tourism opportunities, hygiene level, and accessibility are essential factors in forming a medical tourism image.

Quantitative Research of Medical Tourism Market in Thailand

Introduction. Recently, the medical tourism industry in Thailand has undergone significant qualitative transformations, with the healthcare sector as the main driver of the development and growth of the country's economy. On a global scale, medical tourism in Thailand demonstrates a significant increase in market value that exceeds the global average, ranking in the top five of the most attractive medical tourism destinations.
 A combination of medical services provided by highly qualified specialists, low-cost treatment, as well as ambitious government initiatives allowed Thailand to become one of the industry leaders and a significant hub for healthcare and tourism development. In general, there is a significant potential for market expansion. In particular, Russian tourists are largely represented in Thailand’s tourism market.
 Purpose. The purpose of the study was to identify the key drivers of medical tourism in Thailand that may help to adjust Russian national strategy to the development of medical tourism and the export of medical services within the framework of the Federal Project ”Export of Medical Services” as part of the National Project “Healthcare” upon the Decree of the President of the Russian Federation No. 204 dated May 7th, 2018.
 Results and conclusion. Despite the fact that modern international medical tourism is relatively new, the entry into the market of both a separate medical organization and a governmental one is associated with a high threshold of entry requiring significant legal, infrastructural, scientific, and educational transformations, as well as ensuring the safety of medical tourism services at different levels, from national to municipal and hospital. Thus, the global scientific society is interested in the experiences of the countries that have achieved significant results in the international medical tourism market. Thailand is a striking example of a leading destination for medical tourists from Southeast Asia. The ecosystem of medical and wellness tourism created and supported by the government includes doctors, patients, medical organizations, international certification companies, assistance agencies, and medical tourism agencies. The creation of appropriate conditions for the essential development of all market participants allowed Thailand to begin its journey as a global medical destination in the Eastern Hemisphere.

From Sand to Excellence: A Deep Dive into Abu Dhabi's Rheumatology Landscape.

The Emirate of Abu Dhabi (AD) is the capital and largest emirate of the United Arab Emirates (UAE). The emirate's economic significance stems from non-oil and oil contributions to GDP. The 2022 GDP of Abu Dhabi was USD 230 billion. The government provides services to its residents through digital platforms such as official websites. The Abu Dhabi Health Insurance Law No. 23 of 2005 mandates that residents have access to necessary medical care and services. There is a paucity in the literature on the available rheumatology services in the Arab region. This review article aims to explore the status of rheumatology services in AD for both residents and visitors. It will include an overview of paediatric and adult rheumatology care, accessibility of diagnostic procedures, the integration of electronic medical records, access to medications, the status of postgraduate education, research, and suggestions on how to enhance rheumatology services in AD as a destination for medical tourism.

Mediating Role of Social Media in Medical Tourism Visit Decision: A Behavioural Perspective

Social media (SM) has become the main communication medium for both personal and professional communication on a global scale. Despite its many benefits, it is challenging to persuade consumers to accept and use SM as a platform for exchanging health-related information. In contrast to other businesses where individuals utilise social media to freely share their real-life experiences, marketing medical tourism through interactive communication creates several hurdles owing to sensitive matters such as patient health and underlying risk. Healthcare providers' advertising activities and medical tourists' choices to visit are becoming increasingly reliant on social media platforms. Potential medical tourists should use this technology to benefit from SM and learn more about health care. The goal of this research was to see if SM impacts a person's decision to travel to a medical tourism destination. The researcher’s major focus was on social media platforms as a mediator element for medical tourists, as well as their effect on decision-making. To better understand how new technologies are adopted and utilised, the Unified Theory of Acceptance and Use of Technology (UTAUT) and Theory of Planned Behaviour (TPB) were used to research new technology adoption and user behaviour, respectively. These will serve as the study's fundamental hypotheses. The Statistical Package for Social Sciences (SPSS) and Structural Equation Modelling (SEM) - Partial Least Squares (PLS) will be utilised for data analysis. This study's participants will be medical tourists seeking treatment in Malaysian private hospitals.

OPTIMIZING THE POTENTIAL OF SANUR SPECIAL ECONOMIC ZONE AS TRANSFORMATION INTO MEDICAL TOURISM DESTINATION

Objective: In addition to having a positive impact on the environment, nature tourism in Sanur also empowers the local community. Ecotourism programs and local crafts support community participation in tourism development. The purpose of this research is to find out the potential of the Sanur Special Economic Zone (SEZ) can be optimized for increase local economic growth and providing positive impacts on community welfare. Additionally, this reasearch aims to identify the challenges and opportunities in the development of the special economic zone in Sanur, along with proposing strategies to overcome these obstacles to realize its maximum economic potential. Method: This research uses normative legal research which in this method examines the legal terms of the internal perspective of the legal norms as objects of research. The approach in this research consists of a statute approach, conceptual approach. This research uses 2 (two) legal materials which are primary legal materials and secondary legal materials. Primary legal materials based on Indonesian legislation about this topic of research. The secondary legal materials such as books, legal writing materials for example: law journals, legal research, and official sites. In this research phase, a systematic literature review was conducted which referencing various sources available in various research databases using Preferred Reporting Systematic Reviews and Meta-analyses (PRISMA). Conclusion: The results of this research is that the advantages and benefits of the Sanur SEZ, including outstanding tourism potential, good accessibility, and diverse natural resources, can be a driver of economic growth. Technology and innovation development, collaboration with educational institutions, and intensive promotion are crucial steps to optimize the potential of the Sanur SEZ as transformation into medical tourism destination.

确定医疗旅游的目的地竞争力： 基于AHP-QFD框架的研究

This study investigates the competitiveness of Alanya, a medical tourism destination in Türkiye, and determines appropriate strategies using the analytical hierarchy process and quality function deployment. Data were collected from medical tourism experts to gain managerial insights into the factors affecting the competitiveness of medical tourism. The findings show that medical tourists primarily focus on medical factors such as competence of doctor and quality of treatment. The main strategies to strengthen competitiveness are to create a healthcare-free zone, to increase the number of accredited health care providers, and to encourage the involvement of doctors in academic research and ongoing training. For researchers interested in assessing competitiveness in medical tourism destinations, the study presents general determinants that should be considered in each destination. In addition, the findings show that each medical tourism destination should focus on its own determinants of medical tourism competitiveness when developing its marketing strategies. Finally, it shows that the analytical hierarchy process and quality function deployment approaches can be successfully applied in achieving destination competitiveness and strategic planning, with content validity and importance performance analysis.