A B S T R A C T
Health tourism, as one of the specialized domains of tourism, depends not only on its economic and regional impacts but also on the efficient performance of medical centers and their ability to attract and provide services to international patients. The present study aims to evaluate the efficiency of active medical centers in health tourism in Yazd Province using Network Data Envelopment Analysis (NDEA) and to explain the organizational factors related to their performance based on the European Foundation for Quality Management (EFQM) Excellence Model. The research is applied in terms of purpose and employs a combination of qualitative and quantitative approaches in terms of method. The study population consisted of 10 active medical centers in health tourism in Yazd Province, and the expert panel included 15 specialists in the fields of health tourism and medical center management, who were selected purposively. After identifying and finalizing the indicators, the efficiency of the centers was evaluated using a two-stage Network Data Envelopment Analysis model with variable returns to scale (VRS) and output-oriented orientation in MaxDEA software. The findings indicated that the average overall efficiency of the centers is 0.74, and three centers—A2, B5, and C8—achieved full efficiency. A comparison of the network stages showed that the average efficiency of the first stage, i.e., the attraction and preparation of international patients, was 0.62, while the average efficiency of the second stage, i.e., service provision and outcomes, was 0.93. Furthermore, slack analysis revealed that international marketing and advertising costs have excess consumption in a considerable portion of inefficient centers, and the shortage of foreign currency income, final admitted patients, and certain outputs of the attraction stage are among the most important areas for improvement. The evaluation of the EFQM enabler factors also showed that centers with higher performance obtained higher scores in components such as policy and strategy, processes, partnerships and resources.

Extended Abstract
Introduction
Health tourism has emerged as one of the most significant and rapidly expanding domains of the tourism industry in recent decades. Beyond generating economic and income flows, this domain is associated with the development of specialized services, the enhancement of service delivery quality, and the formation of connections among medical centers, patients, and support networks at the destination. From this perspective, the performance of a health tourism destination depends not only on the existence of medical capacities but also on the ability of medical centers to convert existing resources and capacities into desirable services and outcomes. In fact, the presence of specialized physicians, medical equipment, and appropriate infrastructure can only translate into an operational advantage when the managerial and executive processes related to the attraction, admission, and delivery of services to international patients are also organized efficiently.
In Iran, the availability of specialized human resources, competitive treatment costs, the specialized capacities of certain medical centers, and the existence of natural and cultural attractions have provided a suitable foundation for the development of health tourism. However, capitalizing on these capacities requires a precise understanding of the performance of medical centers and the identification of the areas in which existing resources are not converted into expected outcomes. In other words, the issue is not merely the extent to which centers possess resources, but also how these resources are utilized in the successive processes of health tourism and the degree to which desirable outputs are achieved.
The primary problem of the present study emerges from this very point. In studies related to health tourism, a significant portion of the research has focused on identifying influential factors, barriers, and development strategies in this domain, while the quantitative evaluation of the performance of medical centers—and particularly the disaggregation of the efficiency of the internal stages of the health tourism process—has received less attention. On the other hand, an integrated evaluation of performance based solely on quantitative indicators cannot fully reveal the managerial and organizational dimensions affecting performance. In this regard, the EFQM Excellence Model can provide a complementary framework for interpreting differences in the performance of centers by focusing on factors such as leadership, policy and strategy, partnerships and resources, processes, and learning and innovation.
Accordingly, the present study was conducted with the aim of evaluating the efficiency of active medical centers in health tourism in Yazd Province using Network Data Envelopment Analysis (NDEA). In this regard, the indicators related to the operational process of the centers were first identified and finalized using expert opinions; subsequently, the efficiency of the centers was evaluated within a two-stage network comprising the attraction and preparation process and the service delivery and outcomes process. Thereafter, the slack values of inputs and outputs were calculated to identify areas for improvement in inefficient centers, and finally, the quantitative results were integrated with the evaluation of organizational enabler factors based on the EFQM model. In this way, the study endeavors to provide not only an overall assessment of the efficiency of the centers but also to reveal the performance differences across various stages and the main areas of inefficiency within the studied scope.

Methodology
The present study is applied in terms of purpose and descriptive-survey and cross-sectional in terms of nature and data collection method, conducted with a mixed-methods approach (qualitative-quantitative). In the qualitative phase, the performance evaluation indicators of active medical centers in health tourism were identified, refined, and validated. In the quantitative phase, the overall and stage-specific efficiency of the centers was measured using Network Data Envelopment Analysis (Network DEA). The statistical population of the study consisted of medical centers and hospitals active in attracting and providing services to health tourists in Yazd Province. Based on their track record in this domain, access to performance data, and diversity in ownership and specialization, 10 centers were selected as Decision-Making Units (DMUs). Additionally, in the qualitative phase, 15 experts—including managers and officials of the selected medical centers, faculty members specializing in health services management and health tourism, and experts from relevant institutions—were selected through purposive and judgmental sampling. Practical experience, specialized knowledge, and relevant professional background were the main criteria for expert selection.
Research data were collected through library and documentary studies, interviews with experts, and a researcher-developed questionnaire. In the first stage, the literature related to health tourism, performance evaluation of medical centers, data envelopment analysis, and the EFQM Excellence Model was reviewed, and an initial list of indicators was compiled. Subsequently, given the process-oriented nature of health tourism, the indicators were organized into two stages: "attraction and preparation" and "service delivery and outcomes." To validate the indicators, the Delphi method was employed over two rounds with the participation of 15 experts. The indicators were assessed in terms of relevance to the research subject, clarity, and measurability. After removing or merging inappropriate and similar items, their content validity was examined using the Content Validity Ratio (CVR) and the Content Validity Index (CVI). Ultimately, 11 indicators were selected for inclusion in the network model. To assess the reliability of the ranked sections of the questionnaire and the evaluation of the enabler factors of the EFQM Excellence Model, Cronbach's alpha coefficient was used, yielding a value greater than 0.8. Furthermore, the performance data of the centers were, to the extent possible, cross-checked against supporting documents and information and examined for consistency and reasonableness of values.

Results and Discussion
The results indicated that the average overall efficiency of the centers is 0.74, and three centers—A2, B5, and C8—achieved full efficiency within the framework of the employed model. The most significant finding of the study is the difference between the two stages of the process, such that the average efficiency of the attraction and preparation stage was 0.62, while the average efficiency of the service delivery and outcomes stage was 0.93. Therefore, in the studied sample, the performance gap in the pre-service delivery stage was observed to be greater than in the service delivery stage.
Slack analysis also revealed that the type of inefficiency is not identical across different centers. In some centers, excess international marketing and advertising costs were observed; in others, shortages of specialized marketing personnel or shortfalls in outputs such as admitted patients, foreign currency income, and initial visits were prominent. In center C7, the issue was related to excess operational costs and insufficient patient satisfaction. Therefore, improving the performance of centers cannot be achieved through a general and identical solution for all units; rather, it requires interventions tailored to the type and location of inefficiency in each center.
The evaluation of the EFQM enabler factors also showed that the three fully efficient centers obtained the highest scores on these factors, while centers with lower performance generally had lower scores. This pattern, at a descriptive level, highlights the importance of policy and strategy, partnerships and resources, and organizational processes alongside quantitative performance factors; however, this result does not constitute proof of a statistical or causal relationship between EFQM and efficiency.
Based on the research findings, at the level of medical centers, it is recommended that corrective actions focus primarily on the attraction and preparation stage. Centers such as C6, D10, A1, and B3, which have lower efficiency in the first stage, need to evaluate the effectiveness of their international marketing expenditures and avoid allocating resources without proportionate outputs. In B4 and D9, strengthening specialized and multilingual human resources in the area of communication with international patients is of greater importance. In C7, improving patient experience and satisfaction while simultaneously controlling operational costs should be addressed. In centers A2, B5, and C8, which achieved full efficiency in both stages, maintaining existing mechanisms and documenting managerial and process-related experiences can provide a basis for transferring experience to other centers.

Conclusion
From a provincial policy-making perspective, it is recommended that, instead of general and uniform advertising, the health tourism development program of the province be based on establishing a network among medical centers, specialized health tourism agencies, international intermediaries, and patient liaison units. Furthermore, given the concentration of 80% of the studied centers in the city of Yazd, alongside strengthening the capacity of the provincial capital, the specialized capacity of centers in the cities of Meybod and Ardakan should also be considered in provincial planning. Specialization of services and focusing on comparative advantages, such as infertility treatment, can also contribute to the targeting of marketing and resource allocation, provided that genuine capacity exists and medical requirements are observed.

Funding
There is no funding support.


Authors’ Contribution
All of the authors approved thecontent of the manuscript and agreed on all aspects of the work.

Conflict of Interest
Authors declared no conflict of interest.

Acknowledgments
We are grateful to all the scientific consultants of this paper.