0000-0001-7615-2893 
massiellaizrojo@gmail.comEvelyn González Paris2
0000-0001-6530-9875 evemaegp@gmail.comYenisey León Reyes2
0000-0003-0224-2946 yenileon1985@gmail.comYairín Arteaga Prado3
0000-0002-7995-1655 yairin@upr.edu.cu
Cooperativismo y Desarrollo, January-April 2026; 14(1), e966
Translated from the original in Spanish
Original article
Public policies for the management of health tourism at the local level
Las políticas públicas para la gestión del turismo de salud a nivel local
Políticas públicas para a gestão do turismo de saúde a nível local
Massiel Laíz Rojo Chaviano1 0000-0001-7615-2893 massiellaizrojo@gmail.com
Evelyn González Paris2 0000-0001-6530-9875 evemaegp@gmail.com
Yenisey León Reyes2 0000-0003-0224-2946 yenileon1985@gmail.com
Yairín Arteaga Prado3 0000-0002-7995-1655 yairin@upr.edu.cu
1 Mariel Special Development Zone. Cuba.
2 University of Matanzas "Camilo Cienfuegos". Cuba.
3 University of Pinar del Río "Hermanos Saíz Montes de Oca". Cuba.
Received: 9/01/2026
Accepted: 28/04/2026
ABSTRACT
Public policies are an instrument of governments to solve social problems and represent the way to exploit local endogenous resources. The Cuban policies are aimed at diversifying the tourist offer, with special emphasis on forms such as health tourism. The present study aimed to propose a model of public policies for the management of health tourism at local level. A mixed methodology was used. The study was defined as exploratory, descriptive and explanatory; the methods of analysis-synthesis, induction-deduction, literature review, document analysis, survey and the Delphi method were used. The analysis of methodological background led to the elaboration of a new proposal adapted to the characteristics of the Cuban local context. The objective, principles and premises underpinning the tool were established, as well as the fundamentals of the components and their interrelationships, which contributed to its graphical modelling, and the tool was validated by the evaluation of a team of experts. It was found to be necessary and relevant based on the gaps identified in the scientific literature regarding the design of public policies for health tourism at the local level.
Keywords: local autonomy; local development; decentralization; public policies; health tourism.
RESUMEN
Las políticas públicas constituyen un instrumento de los gobiernos para dar solución a problemáticas sociales y representan la vía para aprovechar los recursos endógenos locales. Las políticas en Cuba apuntan hacia la diversificación de las ofertas turísticas, con especial énfasis en modalidades como el turismo de salud. El presente estudio se trazó como objetivo proponer un modelo de políticas públicas para la gestión del turismo de salud a nivel local. Se empleó una metodología mixta. El estudio se definió como exploratorio, descriptivo y explicativo; se utilizaron los métodos de análisis-síntesis, inducción-deducción, revisión bibliográfica, análisis de documentos, encuesta y el método Delphi. El análisis de antecedentes metodológicos condujo a la elaboración de la nueva propuesta ajustada a las características propias del contexto local cubano. Se estableció el objetivo, los principios y las premisas que sostienen la herramienta, así como los fundamentos de los componentes y sus interrelaciones, lo que contribuyó a su modelación gráfica y, se validó la herramienta mediante la evaluación de un equipo de expertos. Se comprobó su necesidad y pertinencia a partir de las brechas determinadas en la literatura científica especializada respecto al diseño de políticas públicas en turismo de salud a nivel local.
Palabras clave: autonomía local; desarrollo local; descentralización; políticas públicas; turismo de salud.
RESUMO
As políticas públicas são uma ferramenta utilizada pelos governos para abordar problemas sociais e representam um meio de alavancar recursos endógenos locais. As políticas em Cuba visam diversificar a oferta turística, com ênfase particular em modalidades como o turismo de saúde. Este estudo teve como objetivo propor um modelo de política pública para a gestão do turismo de saúde em nível local. Foi empregada uma metodologia mista. O estudo foi definido como exploratório, descritivo e explicativo; os métodos utilizados incluíram análise-síntese, indução-dedução, revisão bibliográfica, análise documental, questionários e o método Delphi. A análise de precedentes metodológicos levou ao desenvolvimento da nova proposta, adaptada às características específicas do contexto local cubano. O objetivo, os princípios e as premissas que fundamentam a ferramenta foram estabelecidos, assim como os fundamentos de seus componentes e suas inter-relações. Isso contribuiu para sua modelagem gráfica, e a ferramenta foi validada por meio de avaliação por uma equipe de especialistas. Sua necessidade e relevância foram confirmadas com base nas lacunas identificadas na literatura científica especializada sobre o desenho de políticas públicas para o turismo de saúde em nível local.
Palavras-chave: autonomia local; desenvolvimento local; descentralização; políticas públicas; turismo de saúde.
INTRODUCTION
The study of public policy and health tourism is an essential step in understanding territorial planning and management processes aimed at achieving local socioeconomic development. The increasing globalization practices on an international scale demonstrate the necessary transformation and modernization of public administration processes.
In Cuba, among the main transformations proposed by the Modernization Model is the combination of centralized socioeconomic planning with decentralization. Therefore, greater autonomy is granted to intermediate and grassroots structures, with special emphasis on the municipality (PCC, 2021). Decree-Law 88 of 2024 (Consejo de Estado, 2024) promotes this principle by strengthening the role of municipal administrations in ensuring essential public services such as healthcare. At the same time, it paves the way for better coordination and management of local resources available for socioeconomic activities not subordinate to government entities, such as tourism.
Decree 140 of 2025 (Consejo de Ministros, 2025) establishes a profound structural change, shifting from a highly centralized model to one where municipalities become key actors in development. This contributes to the design of local public policies by transforming the municipality's role from a mere implementer to an autonomous regulatory body. In this scenario, municipal administrations acquire the power to manage the local tourism offerings, the resources transferred to optimize their infrastructure, and to create their own commissions to coordinate the health and tourism sectors.
Health tourism is not limited to the use of natural resources for therapeutic purposes, but also encompasses the supply of medical products and services. The current growth in demand has generated a new governmental vision, motivated by exchanges and debates for better management of this industry from the field of public policy (Gholipour & Esfandiar, 2025).
The study of methodological frameworks associated with public policy and health tourism reveals significant contributions that highlight the integration of a territorial approach into policy analysis, emphasizing citizen participation, local governance, and the heterogeneity of policy effects. However, methodological proposals that integrate both categories are scarce, and detailed analyses of institutional capacities, intergovernmental coordination mechanisms at the local level, or governance structures that connect local actors are rarely offered. In the Cuban case, research is seldom grounded in established public policy theories, with the exception of studies such as those by González Paris (2008), Torres Paez (2018), and Arteaga Prado (2022).
The analysis of this background allows us to identify, specifically, gaps in methodological tools that link public policies with health tourism: 1) it is not connected to accumulated bodies of knowledge in political science and public administration; 2) predominance of qualitative studies, limited integration of quantitative or mixed approaches; 3) models rarely incorporate explicit policy instruments; 4) most studies use single-case designs with a cross-sectional scope, which limits the generalizability of findings and the ability to evaluate policy effectiveness in the medium and long term; 5) many models are conceptual or prescriptive, affecting their practical applicability; 6) they focus on the interests of specific groups or stakeholders, without considering the real needs of the territories; and 7) the effects of health tourism on local communities are understudied.
As a result of the preceding analysis, the objective is to propose a public policy model for the management of health tourism at the local level. From a theoretical perspective, this proposal will contribute to overcoming the current conceptual fragmentation by integrating fields that are usually treated separately, such as public policy, tourism management, and health economics.
From a methodological perspective, the model will enable the diagnosis, design, implementation, and evaluation of the impact of public policies in local contexts, adapting to resource-constrained environments and fostering interaction among stakeholders through a participatory local governance structure. In practice, it will serve as a tool for addressing the challenges faced by those managing territories with potential for health tourism development, maximizing economic benefits and minimizing negative impacts on the local population.
MATERIALS AND METHODS
The study employed a mixed methodology, with a predominance of the qualitative approach. It was defined as exploratory, inquiring into the public policy and tourism management tools that have been proposed within the national and international frameworks; descriptive, in determining the characteristics of each of the model's components; and explanatory, in addressing the interrelationships established among its constituent elements. The tool's design was divided into three fundamental phases:
1) Theoretical analysis for the design of the public policy model for the management of health tourism at the local level
The main objective is to build a conceptual framework that allows us to understand the nature of health tourism as a public policy problem at the local level, and to identify its determinants and causal relationships.
The analytical-synthetic method enabled a dimensional analysis of health tourism (economic, legal, environmental, social, and accessibility), the characterization and integration of key stakeholders in the design of public policies and the management of this sector. It also allowed for the identification of causal relationships between the model's components and the design of indicators to evaluate the impact of public policies on health tourism.
Induction-deduction method: empirically proven indicators were identified in similar scenarios, and gaps detected in previous studies were considered to optimize the new proposal.
Literature review: existing theories on public policies and health tourism were identified and contrasted; key variables and their causal relationships were defined based on documented empirical evidence.
Document analysis: the legal-regulatory framework that establishes the powers of local governments in the exercise of public policies for health tourism was explored in depth and allowed the construction of the implementation procedure based on the models, manuals and guides used in other scenarios.
2) Construction of the public policy model for the management of health tourism at the local level
The objective was to design the tool itself based on the information processed previously.
In this stage, the tool is modeled, considering its essential components, defining its objective, and outlining the premises and principles that underpin it. Simultaneously, its implementation procedure is designed, aligning with the stages of the public policy cycle.
3) Validation of the public policy model for the management of health tourism at the local level
The objective is to verify that the proposed model is conceptually sound, internally consistent, and relevant before submitting it for implementation.
A team of experts was selected and self-assessed using questionnaires to measure their knowledge coefficient (kc) and argumentation coefficient (ka) and to determine their competence coefficient. Fifteen experts were identified who obtained an index higher than 0.8. The team consisted of 8 academics (from the universities of Havana, Matanzas, Las Villas, and Holguín), 4 managers from the health sector (Faustino Pérez Provincial Clinical Surgical Teaching Hospital and Cuban Medical Services Marketing Company), and 3 from government entities (Matanzas Municipal Administration Council and Matanzas Provincial Government).
The Delphi method was applied for the theoretical validation of the model. Through an initial questionnaire, the components were submitted to expert evaluation (graphical representation, premises, objective, foundations, principles, implementation procedure, and general evaluation). A Likert scale with values from 1 to 5 was used, where: 1-Inadequate; 2-Somewhat adequate; 3-Adequate; 4-Quite adequate; and 5-Very adequate.
The reliability of the instrument was determined using Cronbach's alpha, and its content, criterion, and construct validity were established. Content validity was determined by the research team through expert judgment. Construct validity was calculated using the Kaiser-Meyer-Olkin (KMO) statistic, yielding a value of 0.69. The instrument's criterion validity was established by correlating the model's constructs with the theoretical foundations of reference studies in public policy and health tourism (Miranda Lorenzo, 2024; Ramírez Álvarez, 2023), ensuring the instrument's coherence with conceptual frameworks validated in similar contexts. Frequency statistics such as the mean, mode, and median were analyzed, revealing trends based on the evaluations of the model's components. As part of the theoretical validation, an advanced scientific search was conducted using artificial intelligence tools such as Consensus, Perplexity.ai, and DeepSeek to assess the need for the Public Policy Model for Health Tourism Management at the local level.
RESULTS AND DISCUSSION
The proposed model introduces tourism governance as an inclusive and participatory process. This entails identifying stakeholders who can have a direct or indirect influence on the industry, thereby contributing to positive transformation and improved quality of products and services. The model encompasses the three dimensions of sustainable development: economic, social, and environmental.
The tool advances over previous methodological approaches in at least four key directions: 1) it integrates the public policy cycle with the operational management of health tourism, overcoming the fragmentation between policy design and tourism management; 2) it incorporates municipal autonomy and the level of decentralization as enabling premises, allowing the tool to be adapted to low-middle-income contexts with a centralist tradition, a gap identified in the literature (Zeng, 2026); 3) it prioritizes equity in access to health tourism services without neglecting the resident population, establishing universal accessibility as a guiding principle; and 4) the tool proposes concrete procedures for mapping actors and analyzing influence, operationalizing collaborative governance beyond conceptual statements.
The holistic and transdisciplinary nature of the proposal demonstrates a systems approach, allowing the components to be addressed as a whole based on their interrelationships. The Public Policy Model for Health Tourism Management (Figure 1) has the general objective of proposing a public policy tool for managing health tourism at the local level, enabling the utilization of local resources and the creation of partnerships among stakeholders to optimize health tourism services.
Figure 1. Public policy model for the management of health tourism at the local level
Source: Own elaboration
The following premises are established as the basis for the tool:
Municipal Development Strategy: lays the foundation for municipal management. It comprises guidelines, public policies, programs, and projects, aligned with national and provincial policies.
Municipal autonomy: establishes the degree of independence of municipal government entities to dictate public policies, administer and manage their resources, direct and control local production processes and make decisions concerning their demarcation in relation to territorial development.
Professional preparation of staff: Level of technical-professional specialization of the actors linked to the planning and management of the activity, as well as to the design and execution of public policies from a local perspective.
Level of decentralization: Powers granted to municipal government bodies to manage their resources based on their own planning and to influence the solution of social problems in their demarcation.
Willingness and commitment of the local government: Willingness of government bodies to collaborate with the development of the research and its projection to implement the proposed model.
To achieve this, the following principles must be followed:
Universal accessibility: A condition that allows equitable, inclusive, and autonomous access to products, services, and spaces for people, regardless of their physical or intellectual limitations.
Transparency: The ability of government actors to execute processes explicitly and clearly, providing reliable information to stakeholders for a better understanding and interpretation of the results.
Flexibility: A condition that allows for functional changes, based on the dynamics of the context where the tool is implemented, in order to continuously improve it.
Scope: Delimitation of the framework of action in which the model is framed based on the establishment of its general objective.
Ethics: Moral norms that govern the behavior of the actors involved, both on a personal and professional level, which contribute to strengthening the truthfulness and relevance of the processes to be carried out.
Commitment: A pre-established agreement between government actors and involved entities to contribute to the construction, implementation, and continuous improvement of the tool.
Sustainability: A quality that describes the capacity of the processes implicit in the model to last for a prolonged period of time, contributing to socioeconomic development and the conservation of resources in the space where the tool is implemented.
The local context constitutes the framework for implementing the model. The components involved in the design and management of public policies for the development of health tourism are identified and correlated. Health tourism services in Cuba are established as inputs, with the aim of identifying the potential of each locality to satisfy this type of tourist. The characteristics of the demand are described according to predefined dimensions.
It is proposed to conduct a competitive analysis at the national and regional levels. It is examined the existing infrastructure supporting health tourism services, along with the high level of specialization of human resources. Certifications required of organizations and institutions providing health tourism services are considered fundamental. These certifications represent not only a mandatory requirement in this context, but also a distinctive element, a mark of prestige, and a symbol of the quality of healthcare.
The availability of endogenous resources that contribute to the development of health tourism is studied, enabling the delivery of rehabilitation treatments and therapies in local settings. The key actors involved in the process are examined, grouped into four clusters: 1) local governments, 2) the business sector (state and non-state), 3) the community, and 4) other institutions (health, social, and cultural).
The preceding analysis leads to the formulation and selection of the most viable public policy alternative. Policy alliances among the main actors involved are analyzed. The Ministry of Foreign Trade and Foreign Investment is identified as the main actor in the design of export policies for health services at the national level, and it has representation at the provincial and municipal levels through the Department of Foreign Investment and Cooperation.
Local governments are recognized as the primary users for whom the tool is designed. The implementation of this alternative is projected through public policy actions that lead to the management of health tourism at the local level. The cyclical nature of the public policy development process promotes the identification and evaluation of indicators that allow for determining the levels of efficiency, effectiveness, and efficacy of the public policy as a governance instrument.
The tool is based on a study of the legal, economic, technological, environmental, and socio-cultural aspects. Therefore, it analyzes the legal and regulatory framework, comparative pricing, and foreign exchange earnings to improve the quality of customer service, the availability of technological equipment, and the existence of digital platforms that contribute to positioning Cuba as a health destination.
The environmental framework is studied to prioritize the conservation of local ecosystems available for health tourism. Social equity, inclusion, and cultural characteristics are established as fundamental principles, considering respect for local communities and accessibility for all. The model represents the four stages of the Deming Cycle. Its implementation procedure, comprised of six stages and seventeen steps corresponding to the stages of the public policy cycle, is also explained.
Stage I. Preliminary Preparation
Objective: to form the work team through a process of selection and training of personnel who will contribute to the implementation of the proposal.
Step 1. Creating the work team
Description: Selection criteria are established to strengthen the representation of diverse sectors of society related to the object of study. The Expert Method is applied as a qualitative instrument to validate the competence coefficient of each team member.
Step 2. Training of those involved
Description: Group dynamics are used to promote the exchange of knowledge and information on public policy processes and health tourism. Seminars, workshops, and training sessions are conducted, prioritizing the participation of government stakeholders, health and tourism managers, who contribute their practical perspectives to the approach and development of the model.
Stage II. Background to the implementation of public policies
Objective: to analyze the environment and problems that condition the implementation of public policies for the management of health tourism at the local level.
Step 3. Diagnosis of public policy problems affecting health tourism
Description: A diagnosis of public policy problems affecting health tourism services in the area is conducted. A problem tree is designed to prioritize these problems and align them with objectives, strategic lines, and goals in order to provide effective and efficient solutions.
Step 4. Selection of the public policy to work on
Description: A documentary review is conducted. Documents governing the nation's legal and regulatory framework related to public policies, local governments, health services, and tourism are considered. A comparative analysis of Tourism Policy and Foreign Trade Policy is performed, based on the Congresses of the Communist Party of Cuba since the implementation of the Model for Updating the Economic and Social Policy of the Party and the Revolution in 2011. The main modifications to the legal framework for tourism in the country are identified, corresponding to the characteristics of each period.
Step 5. Characterization of the policy at the local level
Description: A characterization is carried out based on its application in the local context; this allows for the identification of strengths and weaknesses that should be addressed. Document review is used to delve deeper into previous studies, along with in-depth interviews and observations to detail aspects of interest to the research.
Step 6. Study of the Municipal Development Strategy
Description: In collaboration with the Territorial Government and a team of experts, the Municipal Development Strategy is analyzed to understand the direction of territorial development and the priorities of the governing bodies. The analysis focuses on the lines related to the health sector and tourism development in the territory. This process identifies the modalities being promoted and critically analyzes the locality's potential to foster other modalities not included in the plans.
Stage III. Formulation and selection of alternatives
Objective: To determine the most viable and feasible public policy alternatives for implementation that will allow the development of health tourism and the promotion of the potential of the localities.
Step 7. Designing alternatives
Description: An objectives tree is developed to address the identified deficiencies and propose criteria better suited to the needs of the process. The multi-criteria analysis method is applied to select the actions to be implemented, based on the following elements: a) compatibility with the legal framework, b) participation of key stakeholders, c) budget availability, d) sustainability, e) social impact, f) flexibility, and g) monitorability.
Step 8. Feasibility analysis of the selected alternative
Description: The feasibility analysis includes the evaluation of the legal, political, environmental, social, technical and economic dimensions that affect the development of the proposal (Table 1).
Table 1. Dimensions for the feasibility study of a public policy alternative
Dimension |
Characterization |
Legal |
It includes the study of the Constitution of the Republic, the laws, regulations and statutes that govern activity in the country and assign responsibilities to government bodies to design and implement public policies in their area. |
Technical |
Availability of technology to support the implementation of the alternative, from the construction, digital and service infrastructure, to the mastery of the procedures for the use of resources. |
Policy |
It includes the analysis of key stakeholders and public opinion. |
Operation |
Institutional capacity for the implementation of an alternative public policy. This encompasses the available human resources, as well as the logistical support involved in the supply chain, communication efforts, distribution channels, and other factors. |
Social |
Level of incidence and acceptance of a public policy alternative by society or key actors. |
Economic-financial |
It involves analyzing the economic and financial resources available for implementing a public policy alternative, and studying the costs and benefits it generates. |
Source: Own elaboration
Stage IV. Alliance between major policies
Objective: to identify potential alliances between tourism and health policies that contribute to increased service quality and the perception of benefits for both sectors.
Step 9. Identifying the composition of the health tourism policy
Description: This study determines the projections of the Ministries of Public Health and Tourism for developing health tourism in the localities. It is examined the institutional policies that guide the work of the Cuban Medical Services Marketing Company and conducts interviews with government officials and representatives from the sectors involved.
Step 10: Actor identification and mapping
Description: a list of local stakeholders whose activities influence public policy and the development of health tourism is compiled and submitted to the research team for evaluation through a questionnaire. The role of each stakeholder within the studied environment, as well as their level of responsibility, is explained.
Based on the identification of the key actors in the processes that make up the model, a mapping is carried out to determine the level of interrelation between them and with the activities corresponding to the model. The following objectives are established for this research:
Step 11. Level of influence of the actors on the main policies
Description: The level of influence of the identified actors is analyzed. Methodological triangulation is used to obtain data through the application of multiple scientific research techniques.
Stage V. Implementation
Objective: to implement the selected public policy alternative for the management of health tourism.
Step 12. Characterization of the supply of health tourism products and services at the local level
Description: this study identifies and characterizes health tourism products and services at the local level. The analysis considers tourist resources and attractions, healthcare infrastructure with potential for tourism development, service personnel, technology, connectivity, and accessibility.
Step 13. Description of the profile of health tourism demand at the local level
Description: A structured characterization of the health tourism segment is carried out, with implications for supply planning and destination management. The characteristics of the health tourist are examined, taking into account their motivations, sociodemographic and geographical characteristics, and behavioral patterns are identified from the collection and analysis of empirical data (Rojo Chaviano et al., 2026).
Step 14. Identification of actions for the management of health tourism at the local level
Description: a set of public policy actions is proposed to improve the management of health tourism, based on efficient collaboration among the stakeholders involved in the process. The proposed actions are submitted to expert review to validate their feasibility.
Stage VI. Evaluation
Objective: to evaluate the implementation of the public policy alternative designed for the management of health tourism at the local level.
Step 15. Identification of indicators for the achievement of policy objectives
Description: this step involves identifying indicators to evaluate the impact of the public policy implementation. To this end, a literature review and brainstorming session are conducted with the team to define the indicators needed to measure the efficacy, efficiency, and effectiveness of the proposal.
Step 16. Meta-evaluation analysis
Description: a meta-evaluation is applied to help understand the results of policy action evaluations through the analysis of final reports. Given the relevance of this tool, a checklist is designed with items tailored to the study's objectives and characteristics.
Step 17. Study of the behavior of the indicators
Description: once the indicator results have been analyzed and processed, comparisons are made and potential areas for improvement in different processes or procedures are identified. For better results, the design and implementation of a real-time indicator monitoring platform is proposed, which would automate the collection, analysis, and processing of information.
Implementing the procedure requires verifying compliance with the established premises. This necessitates a shift in the perspective of the involved ministries regarding policy design, as a high degree of centralization currently exists, leaving little room for local governments to act in a way that benefits them multilaterally. The government is expected to develop a strategic plan, with expert guidance, to design policies based on the proposed methodological framework, taking into account its solid theoretical, methodological, and practical foundation.
Should any of the premises not materialize, awareness-raising and debate will be required with the stakeholders who have the greatest influence on key policies. Implementation falls to government entities, including the Municipal Administration Council or the Provincial Government, in conjunction with the Municipal or Provincial Assembly of People's Power, depending on the scope of the public policy; the delegations of the Ministry of Tourism; the Provincial Health Directorates; and the management of the Cuban Medical Services Marketing Company.
The theoretical validation of the Public Policy Model for Tourism Management at the Local Level was carried out using the Delphi method. The instrument applied was determined to be reliable, with a Cronbach's Alpha of 0.807. Content validity was established through positive evaluation by the 15 selected experts, and construct validity was established using the KMO statistic with a value of 0.69. A significant correlation was found among the experts, with an overall mean of 4.84; while the frequency statistics show consensus regarding the evaluated elements (Table 2).
Table 2. Evaluation of consensus criteria among experts (Round 1)
Criterion |
Indicator |
Evaluation |
Measures of central tendency |
Median ≥4 - Agreement; Median = 3 - Neutral (excluded); Median ≤ 2 - Disagreement (excluded) |
The median of all components was greater than 4 |
Interquartile range (IQR) |
RIC ≤ 1 Strong consensus; 1 < RIC ≤ 2 Moderate consensus; RIC > 2 No consensus (excluded); RIC > 3 Disagreement (excluded) |
All components have RIC ≤ 1 |
% consensus between 4-5 |
C ≥ 80% Very strong; 70% ≤ C < 80% Strong; 60% ≤ C < 70% Moderate (excluded); 50% ≤ C < 60% Weak (excluded) |
In all components, the percentage of consensus among experts was greater than 80%. |
Source: Own elaboration
All elements of the model were considered adequate, very adequate, and quite adequate (Figure 2). The relevance of the tool in the current Cuban context was recognized, based on its systemic and integrative nature and the need to strengthen decentralization in key sectors for the country's development, such as tourism.
Figure 2. Evaluation of the elements of the Public Policy Model for the management of
health tourism at the local level
Source: Own elaboration
The suggestions of experts were analyzed, who proposed: a) enhancing visual interconnections between internal components; b) including human capital development for both the provision of health services and the management of government processes; c) adding the identification of the territory's natural resources; d) integrating key stakeholders in the design of public policies (Ministry of Foreign Trade and Foreign Investment, BioCubaFarma); e) introducing a study of the supply and demand of health tourism; and f) incorporating accessibility as a component of the model. Regarding the last element, the authors consider it an inherent, critical, and cross-cutting element in its development, and therefore established it as a principle of the tool.
Table 3 summarizes the essential elements identified in the specialized literature on public policy models in health tourism, contrasting them with their expression in the proposal presented.
Table 3. Essential elements in a public policy model for health tourism
Essential elements in a public policy model for health tourism |
Expression in the Public Policy Model for the management of health tourism at the local level |
Consider collaborative governance (Kim & Lee, 2021) |
It includes not only the governing bodies of health tourism policies, but all public or private actors that contribute to the development of this activity. |
Adopting a paradigm shift approach (Kim & Lee, 2021) |
Implementation is contingent upon the decentralization of powers and the granting of local autonomy to carry out the processes developed at this level. This entails a transformation of traditionally centralized management frameworks towards integrated, multi-level, and multi-stakeholder models. |
Articulating multiple dimensions (Loghman Estarki, 2025) |
Dynamic interdependence between the components of the model, from a systemic approach, which operate at different levels of aggregation, emphasizing the local scale. |
Integrating the health system as a central tourism infrastructure (Zeng, 2026) |
It involves enhancing the value of local health infrastructure for tourism, not only as international medical care centers in local areas. |
Recognizing dynamic co-evolution (Zeng, 2026) |
It recognizes the importance of tourism development in parallel with its positive impact on local health systems and the benefits for resident populations. |
Explicitly incorporate equity |
It does not exacerbate the structural inequalities that can be generated by the promotion of health tourism; instead, it prioritizes responsible health governance by incorporating principles of social justice. |
Source: Own elaboration
A systematic comparison with previous literature reveals that health tourism models developed in Southeast Asia (Guo et al., 2026; Liu & Wang, 2025; Tangon et al., 2025) lack from an excessive dependence on national policies with little attention to local particularities (Zhong, 2025). In contrast, the proposed model incorporates decentralization as an enabling premise, which constitutes an innovation for contexts with a centralist tradition.
Despite its contributions, the model has limitations that must be acknowledged. First, the validation has been theoretical, based on expert judgment, so empirical validation in a specific municipality is required to verify its practical applicability. Second, the model presupposes a level of institutional and technical capacity that may not be available in all Cuban local governments. Third, the implementation process demands time and resources that could be difficult to sustain in contexts of economic constraint. Fourth, the model does not address in depth the mechanisms for sustainable financing of the proposed public policy actions.
From a theoretical perspective, the proposal represents a significant advance in understanding and addressing this emerging phenomenon. Local health tourism cannot be adequately understood from a single discipline; rather, it requires an integrative framework that articulates political science with tourism theory and the management of health systems.
The disciplinary fragmentation observed in the preceding literature (health tourism models that ignore health economics or healthcare models that ignore tourism competitiveness) has resulted in incomplete analytical frameworks. The proposed model integrates these theoretical frameworks into a coherent structure, recognizing that health tourism is simultaneously a problem of economic development, healthcare organization, and distributive equity.
The public policy model for managing health tourism at the local level helps overcome the existing conceptual fragmentation between political science, health economics, and tourism management. The proposal explicitly integrates decentralization and municipal autonomy as enabling prerequisites, establishes universal accessibility and equity as guiding principles, and operationalizes collaborative governance through concrete procedures for stakeholder mapping and influence analysis.
For local governments, the tool provides a procedure that allows them to design and manage public policies for health tourism, based on the use of endogenous territorial resources and the creation of alliances between actors for the optimization of health tourism services.
In its conception, the model's components enable the diagnosis of the current situation and its transformation through the management of each component and their interrelationships. The model has been validated theoretically through expert judgment; therefore, empirical validation is required in one or more Cuban municipalities with a tourism focus to verify its practical applicability and measure its impact on management indicators.
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Conflict of interest
Authors declare that they have no conflicts of interest.
Authors' contribution
Massiel Laíz Rojo Chaviano, Evelyn González Paris, and Yenisey León Reyes conceived and designed the study.
Massiel Laíz Rojo Chaviano analyzed the data and performed its collection, analysis, and interpretation, as well as writing the manuscript.
Evelyn González Paris, Yenisey León Reyes, and Yairín Arteaga Prado critically reviewed the manuscript and approved the final version submitted.
