**3. Systemic competitiveness of associative character: A theoretical approach**

It is difficult to study competitiveness as a paradigm when it is still under confusion and ambiguous about the concept, leaving a void in theoretical and practical clarity [15]. The book *The Competitive Advantage of Nations* of Porter is a first conceptual approach to the com‐ petitiveness idea as an end in itself based on the capacity of national enterprises to sustain and increase their participation in international markets with a parallel rise in the standard of living of the population. **Figure 4** shows the Porter´s Diamond Model. The definition is complemented by the diamond model that is characterized by the allocation of four elements that skyrocket the participation of industries in international markets: (1) the conditions of factors, (2) the context for the strategy and business rivalry, (3) the conditions of demand, and (4) the related industries and support. The main criticism of Porter's model is the government role as an exogenous agent that should have a limited influence in the local companies' fight for international markets share. Although the inclusion of the government element implies a better exogenous condition for companies to increase the market share, there is no analysis of how the four factors influence the government in its role as a regulator and promoter of the companies' competitiveness.

On the other hand, Rugman and Cruz [2] include the government element in the Porter's ini‐ tial diamond as illustrated in **Figure 5** called the Rugman and Cruz's Diamond Model, mani‐ festing a more participatory approach in the generation of spaces that creates greater market share to national companies based on complementary elements, as the result of increasingly competitive environments in which the technological differentiation of both processes and the use of digital media strengthen the output production, marketing, sales, and loyalty ser‐ vice of wholesale and retail consumers.

Jones [16] relate the concept of competitiveness to the commercial performance of companies of different legal natures, with the increase of their assets and improvements in population's welfare (quality of life, employment, and impact on the environment), vertical integration, innovation, efficient management of resources, incorporation of new technology, decentral‐ ization of production, etc., relating the three levels of competitiveness: business competitive‐ ness, national competitiveness, and industrial competitiveness.

**Figure 4.** Porter´s diamond model *Source*: Ref. [1].

living abroad, who decide to consume health services in their country of origin as a result of the high prices of procedures in the country where they live. **Table 2** shows the investment in clinics and private healthcare centers in Colombia according to the National Institute of

**of US dollars)**

Portoazul clinic Barranquilla 1015 102 beds, 164 offices, 21 commercial

Hospital Pablo Tobon Uribe Medellin 1135 400 beds, 100 intensive care beds, 16

Hearth center Bucaramanga 104 96 enabled beds, invasive and

Ibanmaco Medical Center Cali 95 196 Beds distributed in adult

Cardiovascular Hospital Bucaramanga 214 205 beds, 13 operating rooms, 27

**Observations**

services.

care.

beds.

locations, specialized diagnostic center.

noninvasive cardiology procedures

operating rooms, specialty in bariatric surgery and internal medicine.

hospitalization, pediatrics and intensive

intensive care beds, 14 intermediate care

**Figure 3.** Investment in infrastructure according to the category of medical tourism in 2016. *Source:* Ref. [11].

**3. Systemic competitiveness of associative character: A theoretical** 

It is difficult to study competitiveness as a paradigm when it is still under confusion and ambiguous about the concept, leaving a void in theoretical and practical clarity [15]. The

**Table 2.** Investment in clinics and private healthcare centers in Colombia according to the National Institute of Technical

Technical Standards and Certification in 2016.

130 Mobilities, Tourism and Travel Behavior - Contexts and Boundaries

**Private medical centers Location (City) Investment (millions** 

**approach**

*Source*: De la Puente [14].

Standards and Certification in 2016.

**Figure 5.** Rugman and D´Cruz´s diamond model *Source*: Ref. [2].

De la Puente [17] establishes that business competitiveness results from the allocation of goods and services, while national competitiveness relates to the generation of an environ‐ ment conducive to industrial competitiveness. That is, the government as a regulating agent and facilitator of economies of scale moving away from the perspective of Porter and Rugman in the sense of indirect promoter of international trade.

Unlike the traditional perspective mentioned above the generic concept of competitiveness in which the government is only a regulator, facilitator, and promoter of the expansion of mar‐ ket niches for national companies focused on favorable macroeconomic conditions (which visualizes competitiveness as a result of the conditions of "*macro"* variables and their influ‐ ence on the costs of production and factor prices), the *neolaborism* (which mentions that labor is essential for a competitive advantage, assigning investment an equal importance), and *institutionalism* (which gives importance to the role played by institutional aspects in man‐ agement, innovation, and learning) are included in the systemic competitiveness approach. Systemic competitiveness is the result of a complex and dynamic interaction patterns between the government of a country, companies, intermediary institutions, and the organizational capacity of a society; this model is based in four levels: *micro, meso, macro,* and *meta.*

Systemic competitiveness is characterized by recognizing that the success of an industrial development is not only achieved by a production function at the *micro* level or as there are stable macroeconomic conditions, but also as there are government measures and policies that encourage competitiveness in companies or organizations from the combination of an environment that incentives social, judicial, political, and macroeconomic stability, including the adaptation of sociocultural elements that projects social competitiveness (target level). According to the Organisation for Economic Co‐operation and Development (OECD) report *Developing of OECD Competitiveness Indicators Platform*, it summarized and systematized these approaches into a comprehensive vision that it is called "structural competitiveness" [18]. At the *micro* level, the expansion of the government presence in production and sale of goods and services is highlighted, based on its strategies for brand positioning, economies of scale, and consumer loyalty (if applicable).

The *meso* level relates to the limited cooperation networks of business organizations that require the participation of government and nongovernmental agents; in this way, the policies that create the *meso* level have a cross‐national policy dimension. **Figure 6** illus‐ trate the Altenburg, Hilebrand & Meyer‐Stammer's systemic competitiveness model [19]. This is the case of improved access and quality of public services, increased coverage and methodological quality of the education system from various angles, universal coverage of access to a high quality of the health system, strategies for positioning goods and ser‐ vices abroad, promotion of domestic and foreign investment, both direct and indirect, to

**Figure 6.** Altemburg, Hilebrand & Meyer‐stamer´s systemic competitiveness model *Source*: Ref. [19].

De la Puente [17] establishes that business competitiveness results from the allocation of goods and services, while national competitiveness relates to the generation of an environ‐ ment conducive to industrial competitiveness. That is, the government as a regulating agent and facilitator of economies of scale moving away from the perspective of Porter and Rugman

Unlike the traditional perspective mentioned above the generic concept of competitiveness in which the government is only a regulator, facilitator, and promoter of the expansion of mar‐ ket niches for national companies focused on favorable macroeconomic conditions (which visualizes competitiveness as a result of the conditions of "*macro"* variables and their influ‐ ence on the costs of production and factor prices), the *neolaborism* (which mentions that labor is essential for a competitive advantage, assigning investment an equal importance), and *institutionalism* (which gives importance to the role played by institutional aspects in man‐ agement, innovation, and learning) are included in the systemic competitiveness approach. Systemic competitiveness is the result of a complex and dynamic interaction patterns between the government of a country, companies, intermediary institutions, and the organizational

capacity of a society; this model is based in four levels: *micro, meso, macro,* and *meta.*

Systemic competitiveness is characterized by recognizing that the success of an industrial development is not only achieved by a production function at the *micro* level or as there are

in the sense of indirect promoter of international trade.

**Figure 5.** Rugman and D´Cruz´s diamond model *Source*: Ref. [2].

132 Mobilities, Tourism and Travel Behavior - Contexts and Boundaries

enhance competitive advantages. For the *macro* level to have an effect on the overall strat‐ egy of systemic competitiveness, it must ensure stable macroeconomic conditions, as well as achieving the objectives of economic growth and competitiveness.

To achieve the goal level, it is necessary to coordinate the objectives of the previous levels, tak‐ ing into account the scope of a long‐term welfare state (understood as the change in the concept of information sharing between competitors, state agents, civil society, consumer responsibility to determine the positive and negative impacts in business organizations, the ability to formu‐ late sectorial strategies, policies that imply an improvement of civil society, and social cohesion through incentives, not imposition through coercion). On the other hand, it is at this level that the social structure that complements the economic structure takes shape, so that networking, horizontal coordination, and social integration must be strengthened [20].
