PurposeTourism industry is a profitable resource for countries and considered one of the main sources of income and job creation for economic development. Among the various types of tourism, medical tourism and its subsets are of great significance owing to their capabilities and competitive advantages. In this regard, the purpose of this research is to provide a framework to categorize customers based on the Zeithaml pyramid and then identify and provide strategies to create loyalty and attract customers of this industry.Design/methodology/approachThis study proposed a framework for medical tourists' satisfaction and loyalty. First, by studying the literature and data gathering from Yazd (one of the cities of Iran), the effective factors on the loyalty and attraction of medical tourists were identified. These factors have been prioritized for the medical tourists who are in the platinum category by the Pareto technique and Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method. Next, the strategies provided by experts for loyalty and attraction of medical tourists were examined. Finally, the house of quality (HOQ) as the first matrix in quality functional deployment (QFD) was used to provide operational strategies for medical tourism satisfaction. The statistical population of this research consists of medical tourists, academic experts and active physicians of medical tourism in Yazd, one of the cities of Iran.FindingsThe study results indicate the importance of “hospital reputation” in medical tourists' satisfaction. Also, “achieving international standards”, “periodic customer satisfaction assessment” and “paying attention to social responsibilities” are recognized as the most important strategies to achieve the loyalty of the most profitable group of customers, namely platinum.Practical implicationsThis study covers both theoretical and practical aspects. Theoretically, this study developed a new framework for medical tourists' satisfaction by the Zeithaml matrix, TOPSIS, Pareto technique and QFD method. Furthermore, practically this study helps practitioners of medical tourism in medical tourists' satisfaction and loyalty.Originality/valueIn this study, in addition to identifying the effective factors on the loyalty and attracting medical tourists, a new framework was developed for medical tourists' satisfaction by segmentation the tourism by the Zeithaml matrix and providing operational strategies by the QFD technique.