C M Y K

5
5.1.1

Opportunities, Challenges and Strategies for India

5.1 OPPORTUNITIES
Increase in Ageing Population and Cost of Healthcare in Developed Countries Healthcare is one of the fastest growing sectors, both in India and abroad. People are increasingly becoming health conscious and are in lookout for quality healthcare systems that would provide solutions in a holistic way. There has been an increasing number of ageing population, putting additional burden on the already overburdened national healthcare systems in developed countries. (Annexures 4 and 5). Increase in cost of health insurance is adding the number of uninsured population in these countries (Annexure 6). According to a study43 by PriceWaterHouseCoopers, the cost of premium for health insurance during the period 2004-2005, has gone up by 8.8% in USA. Cost increase is being attributed to general inflation, increase in cost of healthcare services (cost of updated technology, broader access plans) and increase in utilization (aging, lifestyle, new treatments). Such a scenario provides opportunities for Indian healthcare sector.

43

The Factors Fuelling Rising Healthcare PricewaterHouseCoopers, USA, January 2006.

Costs

2006,

149
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

5.1.2

Professional Skills and Experiences Gained from Developed Countries Many analysts have predicted that healthcare tourism will be one of the next big opportunities for India. Such predictions are on the grounds that India is one of the countries with highly skilled professionals and with advanced healthcare solutions. It may be mentioned that Indian doctors have been serving in developed countries such as USA, UK and Canada and have gained high reputation. In addition, Indias popularity in the international arena is increasing with the prevalence of traditional wellness systems, especially Ayurveda and Yoga. It is estimated that a large number of tourists have visited India to practice the wisdom of Indian wellness systems. 5.1.3 Multi-language Skills Multi-language skill, which is one of the prominent interfaces while availing healthcare as also the tourism services abroad, is another advantage for India. In addition to proficiency in English, Indians are proficient in speaking Hindi, Urdu, Bangla, Arabic, Tamil, which are widely spoken in neighbouring countries of West Asia, South and South East Asia. 5.1.4 Low-cost Healthcare Solutions with High Success Rate Another reason for India emerging as a major destination for healthcare is the low cost of treatment prevailing in India. Indian hospitals are cost effective than many developed countries such as USA and Europe. Even when compared to other South-East Asian countries, such as Thailand and Singapore, India scores better, with the cost of procedures cheaper by around 20 percent. There are estimates that by 2008, companies in USA will be spending as much on healthcare as they made profits, forcing the scaling back or withdrawal of benefits. As precaution, some firms have begun considering treatment for their employees in low cost destinations. Thus, low cost healthcare services coupled with internationally acceptable medical practices would position India as an attractive healthcare destination. Estimates show that the average success rate of cardiac surgeries in Indian hospitals compares favourably with developed countries. The success rate of Indian physiotherapists helping patients regain their physical
150
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

fitness and prevent cardiac problems is at an average of 99.5 percent, at par with leading cardiac centers around the world.

5.1.5 Long Waiting Time in Developed Countries Long waiting time in several countries works in favour of growth in healthcare tourism flows towards developing nations. Countries, such as UK and Canada, that provide free healthcare services to their citizens thus become a source for large number of healthcare tourists visiting India. Indian players could leverage quality in services rendered alongwith low cost healthcare solutions, to attract more number of patients from these countries into India. 5.1.6 Industry Level Initiatives At industry level, several initiatives are taken to showcase India as a healthcare destination. First and foremost is formation of Indian Healthcare Federation to voice the concerns of the industry. Indian healthcare establishments are also working closely with other stakeholders such as hotels, travel agents, tour operators and airlines to offer healthcare tourism as a composite service. While doing so, patient safety is being ensured through collaborative efforts of various stakeholders.
Some healthcare service providers have formed strategic alliances with leading healthcare establishments in the world. Efforts are being made to tie-up with national healthcare systems abroad and social / commercial insurance providers. Few of them have also established alliances with academic and research institutions abroad to update on medical technologies and practices. Players are imparting hi-tech equipments and medical infrastructure such as the da Vinci Surgical System for Robotic Cardiac Surgery, 64 slice CT Scan, Linear Accelerators similar to Sloan Kettering, New York44. Strict blood safety and infection control processes are installed. Some healthcare establishments are offering free specialized healthcare camps as also free surgeries under the umbrella of corporate social responsibility. Data generated through such camps are used extensively in their research and development activities.
Incredible India : The Global Healthcare Destination, Ministry of Tourism, Government of India, 2006.
44

151
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Leading players of the industry are looking at accreditation intensively - be it from national or international accreditation agencies. Initiatives are also being taken to offer healthcare services by way of setting up of healthcare establishments abroad. Some of them have also established their presence abroad through leveraged buy-outs. Interesting feature is that establishment of healthcare institutions abroad is also in the traditional wellness systems, such as Ayurveda and Yoga. Indian healthcare establishments, focussing on international tourists, have started providing associated value added services such as arranging accommodation, facilitating completion of travel documentation, travel arrangements, translation services and escort services. Such initiatives have been projecting Indias prowess in hospitality skills as also a destination for healthcare solutions.

5.1.7 Government Initiatives Government has also been supportive of the initiatives taken by the healthcare and tourism industry to realize the potential. The center and many state governments are encouraging healthcare / tourism firms to participate in international fairs and promotional programmes to showcase the capabilities of India. Many state governments have unveiled specific policy supporting healthcare tourism. State governments, such as Kerala, are leveraging their specialization in Ayurveda and have announced customized policies to attract healthcare tourism.
Government of India has announced two separate national policies for development of a) healthcare, and b) tourism. Government of India has formed a Task Force on Medical Tourism with the objective to suggest policy framework to project India as a healthcare destination. The Government has set up National Accreditation Board for Hospitals to provide accreditation to public and private hospitals ensuring quality in healthcare services. The Government has announced a policy framework for issue of Medical Visa to ease the immigration procedures of healthcare and accompanying tourists. Foreign Direct Investment is permitted upto 100 percent for setting up of hospitals as also hotels and tourism projects in India.

152
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

5.1.8 Spillover Effects Promotion of healthcare tourism not only helps in development of the two major sectors, viz., healthcare and tourism, but also associated services sectors. With more and more investment going into setting up of specialty hospitals, it is expected that the medical devices and equipment segment would witness considerable development. Industry estimates suggest that around one-third of capital expenses in setting up of super specialty hospitals go in for procurement of medical devices and equipments. The increase in automation, demand for hi-technology, computer aided apparatus, diagnostic and medical laboratory equipments would help in attracting investment, technology transfer, and FDI in the Indian medical equipment sector.
The world healthcare industry, in order to cut down the cost, is outsourcing its research and administrative expenses. In addition, the volume pressure would mandate several health maintenance organizations to outsource portion of their work to low cost destinations. Information technology is becoming a major enabling sector for healthcare delivery all over the world. At present, healthcare organizations are estimated to be outsourcing around 10% their IT requirements. However, in the near future, the share of IT outsourcing is expected to increase providing opportunities for Indian IT capabilities. India has been traditionally attracting outsourcing business in medical insurance claim processing and digitising the patient health records (medical transcription). This is being further strengthened with outsourcing of high-end services such as clinical data analysis, biometric services and chemical engineering. Indias strengths in IT and IT enabled services could be leveraged to support such knowledge processing activities. Leveraging information technology, a specialist or a super specialist in a hospital could give advice to the patients or even monitor the patients health conditions. Similarly, medical students can observe conduction of operations in another location leveraging information technology. The concept of telemedicine would become more and more popular with an increasing outsourcing of healthcare services. In addition, the biggest beneficiary of the
153
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Box 21: Government Support for Ayurveda R&D Centre

Government of India, under its Industrial Infrastructure Upgradation Scheme, has approved funding support to the Confederation of Ayurvedic Renaissance Keralam (P) Ltd, CARe Keralam to set up a research and development laboratory for scientific validation of ayurvedic herbal drugs. CARe Keralam, a venture of Kerala Industrial Infrastructure Development Corporation, Kerala State Industrial Development Corporation and the Ayurveda industry, would establish analytical lab, toxicology study centre, process validation lab, raw material storage facilities, IT and marketing infrastructure, and common facility centre for production and marketing. The consortium would take efforts towards documented validation of products as well as processes, quality control procedures, and analysis of toxicity profile to establish efficacy of products. In addition, the consortium would work on documentation of various Ayurvedic products, which is a pre-requisite for marketing of Ayurveda products as drugs in foreign markets. The consortium is planning to standardize Kerala Ayurvedic treatment sector also. A brand logo will be given for these branded products to the members of the consortium.
Source: CARe Keralam; www.carekeralam.org

concept of telemedicine would be the rural population, who has limited access to medical facilities. Another area of opportunity is health insurance business as also outsourcing of health insurance. Although the penetration of healthcare insurance is only 10% in India, Insurance Regulatory and Development Authority views the health insurance is one of the fastest growing portfolios of general insurance business. In addition to increase in volume of health insurance business (for coverage of domestic population), healthcare tourism would bring opportunities with another new term / concept of medical insurance outsourcing. This could happen if national healthcare systems in developed countries outsource the healthcare services to India.
154
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

In addition to the healthcare and wellness associated travel, there are also opportunities for India to tap the preventive healthcare segment. Growing health consciousness among middle and highincome families of developing countries is heralding such opportunity. Besides, developed countries are in the process of outsourcing laboratory and diagnostic tests to low-cost destinations. It is being reported that highly specialised tests like molecular diagnostics, cytogenetics or tests for diseases related to abnormalities in chromosomes and hormones, infectious diseases and hepatitis B and C are outsourced to countries like India due to advancements in the healthcare sector and availability of professionals. Further, it is estimated that Indian laboratories are cheaper in undertaking pathological tests as compared to developed country markets. There are estimates that laboratory / diagnostic outsourcing market in the world is approximately US $ 1 billion. There are also opportunities in the infrastructure sectors, due to higher demand for travel (airlines, road / rail transport, hotels, hospitals) and communication (telephone, internet). Newer models of campaigning and promotions provide business opportunities for media and mass-communication segments. Consultants, in wide spectrum of areas covering healthcare, tourism, infrastructure, communications, media, marketing and promotions, are likely to get business opportunities with the growth of healthcare tourism in India.

5.1.9 Increasing Awareness of the Physical Beauty Preserving and improving ones physical beauty has become the fashion today. The growing number of fitness centers is an example that could be cited. One is so aware and conscious of ones health and physical appearance that they go to any extent to preserve them. The movies have also been playing a role by motivating people to have good physical structure so that they are physically more attractive.
With an increasing awareness regarding beauty and body solutions, the demand for reconstructive surgery, especially plastic surgery has been accelerating steadily over the years. The healthy competition amongst several health and fitness agencies in this

155
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

regard has not only resulted in improved outcomes but also made the treatment cost affordable45. The urging need to be healthy and physically attractive has also led to an increase in the number of people interested in pursuing this profession as a career. The increasing demand from health centers is also helping such individuals earn good income.

5.1.10 Availability of Manpower India has been producing a lot of young professionals in the fields of medicine, including specialization in some of the traditional systems. In addition, many graduates are trained on the job in the travel and tourism industry, which also caters to the growth of healthcare tourism. The concept of freelancing is also picking up fast in India, especially in the traditional healthcare segment, where the healthcare professionals provide their services traveling to various places and offer their services across the world. As the availability of highly skilled healthcare professionals, and well-trained travel / tourism professionals are the determinants of growth in healthcare tourism industry, India is considered as potential land for healthcare tourism business. 5.1.11 Tradition of Nutrition Values India is popular for its culinary traditions. Many spices used in Indian culinary traditions are claimed to be having medicinal properties. Even some of the tropical Indian vegetables are claimed to be having medicinal properties. The awareness among the people to be healthy has been encouraging them to consult nutrionists and dieticians for their overall health improvement. Naturopathy is also one of the traditional Indian systems of medicine. Many nutritionists and consultants trained in the naturopathy are advocating special natural way of diets for various ailments. Consultancy services are provided by nutrionists which is a great opportunity for people engaged in that field. The number of students enrolling for the nutrion and dietetics course is also witnessing a rise due to the diverse opportunities that the field provides.

45

Source: http://www.cosmeticsurgeryarticles.com/node/158

156
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

5.1.12 Climate and Geography India has tropical weather with climatic variations occurring from region to region. The coolest months are from November to mid March and the hottest are from April to June. The monsoon rains are experienced from mid July to September. India has been attracting a lot of tourists with such diverse climate and geography.
For tourists, India provides ample opportunities to participate in diverse activities in different parts of the country. The northern plains of India have extreme climates with hot summers and the most favored season is the winter, which attracts lot of tourists who wants to enjoy cool climates. The western Himalayas provide opportunities for trekking, hiking, water rafting during the summers attracting plenty of adventure lovers. Southwest India offers good sunny days and cool breezy evenings during the mid November to mid March after which the climate tends to be hot. These varied climates provide opportunities for the country to attract tourists with different tastes throughout the year.

5.1.13 Millennia Old Health Traditions Ayurveda is one of the most ancient living traditions in the world. It has attracted global interest for many decades and still continues to do so. Indias traditional systems of medicine provide a great source of refreshment and propogates a very healthy approach mainly because it concentrates on the patient more than the disease. It aims at promoting health and enhancing the quality of life by providing treatment through a holistic pattern. Yoga is another major tradional method of enhancing ones health. Performing Yoga exercises helps a person to remain healthier and these healthcare traditions are considered to be a natural antiageing phenomenon.

5.2 CHALLENGES
5.2.1 Healthcare Infrastructure Healthcare infrastructure indicators of India vis--vis developed countries highlight the disparity and areas for improvement. Within the country, the difference between rural and urban India as also the inter-state comparison show the existence of differences across regions.
157
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Number of hospitals, including primary health centres, dispensaries in India is estimated at over 200,00046 with total bed capacity of around 900,000. The bed capacity in terms of population is lower at 89 per 100,000 persons47, as compared to many other developing countries. According to industry estimates, over threefourth of the countrys healthcare infrastructure is in urban areas, compelling the rural Indians move to urban areas for healthcare solutions. There are estimates48 that India would be required to increase its bed capacity with an addition of nearly 1 million beds to match with the bed capacity of China. Another estimate has put the need for India to increase its bed capacity by at least 100,000 per annum for the next five years. The need for hospital beds is also significant to meet the growing demands from population.

5.2.2 Low Spending on Healthcare The primary reason for low level of healthcare infrastructure in India is low level of healthcare expenditure as a percentage of GDP. The per capita total expenditure on health in India, at average exchange rate, works out to US $ 27 in the year 2003 49 . Governments health expenditure accounts for less than one-fourth of total health expenditure in India, and thus do not drive the private sector to increase its investment. With limitations in public healthcare spending, private sector has a major role to enhance the healthcare infrastructure in India. A comparison of healthcare expenditure as a percentage of GDP in India vis--vis select countries is given in Exhibit 23.

46

National Health Policy, Government of India, 2002; http://mohfw.nic.in/ depth.htm

National Health Profile 2005, Central Bureau of Health Intelligence, Government of India, June 2006

48 Ernst & Young, India Brand Equity Foundation, Booklet on Healthcare India 49

Working Together for Health, World Health Report, 2006, World Health Organisation, 2006.

158
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 23: Healthcare Expenditure as Percentage of GDP in Select Countries

Source: Working Together for Health, World Health Report, 2006, World Health Organisation, 2006

5.2.3 Accreditation India is gaining the advantage of being the low cost destinations for healthcare services. However, the healthcare industry needs to prove that the low cost services offered by them are in real terms and the quality of services offered is comparable with developed nations. One of the ways to prove ourselves quality conscious is to get international accreditation of healthcare facilities. There are only few hospitals that have been accredited by international agencies such as Joint Commission International. Although, India has established a national accreditation system for healthcare establishments, very few hospitals have applied for accreditation.
Such accreditation will be beneficial for both hospitals as well as patients. As the accreditation process, especially from an international agency, involves rigourous checks on the processes and procedures employed by these hospitals, it helps the healthcare service providers in improving their overall efficiency and management of healthcare services. Patients are assured of quality in the procedures administered while availing healthcare services, through such accreditation, and thus are satisfied. Hence, Indian hospitals need to go for national as well as international accreditation to remain competitive.
159
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

5.2.4 Low Level of Medical Insurance Coverage Penetration of health insurance in India is low. The organized sector provides healthcare insurance to only 10 percent of population. However, majority of them are covered under the social health insurance or community-based insurance. The penetration of commercial health insurance in India is estimated at around 1 percent only. Major reasons for low penetration of commercial health insurance include low level of innovation in health insurance products, exclusions and administrative procedures governing the policies, and chances of co-variate risks, such as epidemics, which keep the premium high.
The need for greater insurance coverage may be viewed in the context of its potential to create demand for services, while spreading the risks through a pooling mechanism. The insurance coverage may ease out the financial difficulties of patients and help the healthcare service providers with faster return on investment (with increase in demand for services) through lower payback period. Another challenge is that the foreign insurance companies are not willing to extend their coverage for treatments in low cost countries, such as India, as they have concerns about the quality of health services offered. The insurers are of the opinion that insurance coverage for treatments in low-cost countries could prove expensive if the treatment worsens the health conditions and the insurer is obliged to cover the costs of subsequent treatment, at home country. The insurers are also concerned with absence of malpractice law in a foreign jurisdiction in which case the patient will have no recourse to his / her healthcare expenses.

5.2.5 Negative Perceptions Experiences suggest that low-cost solutions alone may not be enough to bring-in international tourists for undergoing healthcare treatments in India. The negative perceptions about India, with regard to public sanitation / hygiene standards, prevalence of contagious diseases in India, quality of healthcare services provided in public sector hospitals, and wastage management practices adopted in India, counter the positive vibes created by the cost competitiveness of Indian healthcare system. Other infrastructure associated problems such as shortage of air linkages, power,
160
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

water, and traffic congestions also affect the flow of healthcare tourists towards India.

5.2.6 Quality of In-country Healthcare Quality healthcare along with faster healthcare delivery is vital for the growth of any nation, as these are basic pillars of an effective healthcare system. The quality of healthcare in a country depends upon various factors such as access, effectiveness, safety and affordability. While, India is considered as a low cost healthcare destination for the world, the cost of treatment in private hospitals are unaffordable to significant share of population considering the present state of public sector healthcare systems and low insurance (both social and commercial) penetration.
India is also having an increasing burden of diseases, both communicable and infectious. Projection50 of disease burden also shows a grim picture with a large number of persons with infections, such as HIV, diabetes, cancers and cardio-vascular diseases by 2015. Table 13 provides projected disease burden in India by 2015. While under-funding is the prime reason for the current state of in-country healthcare scenario, many experts have opined that poor healthcare management practices in the public healthcare delivery, especially at the primary level, are other important reasons for the low quality of healthcare delivery in India. It is important to recognize that international healthcare travelers would not like to take risk when communicable diseases like Dengue, Chikungunya are prevalent in a country. In fact, travel advisories are issued in case of prevalence of such diseases in any country. It may be noted that even if hospitals are fully sterile, some infections are airborne. Thus, it is important to focus on incountry healthcare to create positive perceptions about India as a safe healthcare destination.

5.2.7 Transplantation Law Organ transplantation is a revolution in the medical history as it has helped in saving the lives of those who would have died
50

Report of the National Commission on Macroeconomics and Health, Government of India, August 2005.

161
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

otherwise. Kidney, Liver, heart, lung, pancreas, small bowel are some of the organs that can be donated for an organ transplant. The Human Organs Transplant Act, 1994 has laid down various regulations that have to be followed while conducting the organ transplantation in India. According to the Act, any unrelated donor has to file an affidavit in the court of magistrate stating that the organ is being donated out of affection. The Authorisation Committee, setup for the purpose of approval of organ transplantation with the organ of a non-related donor, ensures that the required documents are complete in all respects before the transplantation. The Act does not permit foreigner availing organs from a local donor.
Table 13: Estimated Disease Burden in India Diseases / Health Conditions Estimated Number of Cases (2005) 85 51 760 Projected Number of Cases (2015) NA 190 880

Communicable Diseases Tuberculosis (lakhs) HIV / AIDS (lakhs) Diarrheal Diseases Episodes (lakhs) Malaria and Other Vector Borne Conditions (lakhs) Leprosy (lakhs)

20.37 3.67

Otitis Media 3.57 Non-Communicable Diseases Cancers (lakhs) 8.07 Diabetes (lakhs) 310 Mental Health (lakhs) 650 Blindness (lakhs) 141.07 COPD and Asthma (lakhs) 405.20 Cardiovascular diseases (lakhs) 290

NA Expected to be eliminated 4.18 9.99 460 800 129.96 596.36 640

Source: Report of the National Commission on Macroeconomics and Health, Government of India, August 2005

162
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

According to a survey by World Health Organisation, transplantation tourism is emerging in the world scenario, with increasing number of patients moving to other destinations where the transplantation laws are less rigid. The survey has concluded that the most sought-after organ is kidney, with more than 66,000 kidney transplantation in 2005 representing a mere 10% of the estimated demand. In the same year, 21,000 livers and 6,000 hearts were transplanted in the world. Both kidney and liver transplants are on the rise but demand is also increasing. Countries like Singapore have an enabling organ transplantation act, which promotes transplantation tourism. It is reported that Indian patients are also traveling abroad principally for undertaking transplant surgeries, as the domestic laws are stringent.

5.2.8 Shortage of Hotel Accommodation With the booming economic growth, the demand for hotel accommodation in India is increasing. There are about 1.2 million hotel rooms in the country, of which approximately 80,000 are in star category hotels51. The availability of hotel rooms is considered to be lower as compared to other countries. In addition, the cost
Box 22: The Transplantation of Human Organs Act, 1994

The Transplantation of Human Organs Act, 1994 is meant to provide for the regulation of removal, storage, and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealings in human organs. The Act prevents the buying and selling of human organs and makes such transactions a criminal offence. The Act establishes an institutional structure to authorise and regulate human organ transplants and regulates the healthcare institutions, through registration and regular checks, to prevent unauthorized transplantation. The Act recognises, the concept of brain-stem death, paving the way for a cadaver-based transplant programme.
Source: Exim Research Manpower Requirement in Hotel Industry, Market Pulse Report, Ministry of Tourism, Government of India, February 2004.
51

163
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

of accommodation and dual tariff system are also hindrances to international travellers visiting India.

5.2.9 Shortage of Medical and Para-medical Staff India has over 600,000 physicians with a density of 0.60 physicians per 1000 population (Exhibit 24). However, there is a shortage of qualified specialist nurses and paramedical professionals as also qualified hospital administrators. Number of nurses per doctor in India is estimated to be 1.33, as compared to 5.27 in UK and 4.67 in Canada (Exhibit 25). Thailand, another developing country competing in the world healthcare tourism market has 7.64 nurses per doctor. One of the main reasons for low ratio of nurses to doctors in India is cross-border movement of nursing professionals from India. 5.2.10 Inadequate Malpractices Law There are debates about whether inadequate malpractices law in India serves as a deterrent or facilitator for flow of healthcare tourism in India. Experts are of the opinion that the present flow of healthcare tourism to India is principally the non-insured population abroad. It is also opined that medical malpractice insurance is a common reason for increase in cost of medical treatment, increase in waitlist, delay in procedures / treatment, and movement of professionals to other regions. Assuming that these two opinions are facts, the inadequate malpractices law in India has facilitated the flow of healthcare tourists to India.
However, it may be noted that the developed countries are working towards easier mobility of patients to other countries with payment coverage under the social healthcare systems as also the private insurers are interested in extending the coverage of healthcare expenditure incurred in other countries. When such an opportunity arise, the national governments, as also the private insurers, would look for low cost destinations that have better malpractices law in place. A better malpractice law regime provides recourse to the patients who develop complications or side effects after they reach the homeland. It may be mentioned that, recently, the United Steel Workers Union, one of the largest industrial workers associations in USA, has lodged a complaint in the Senate and House Committee to arrest the flow of healthcare tourists from
164
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 24: Distribution of Health Workers in Select Countries

Source: Working Together for Health, World Health Report, 2006, World Health Organisation, 2006

Exhibit 25: Nurse - Doctor Ratio in Select Countries

Source: Working Together for Health, World Health Report, 2006, World Health Organisation, 2006

165
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

USA to other countries, especially in view of absence of liability insurance and appropriate recourse in case of medical negligence.

5.2.11 Competition from Spas in Domestic and International Market. India has also seen the growth in number of Spas in the last few years, which has increased the awareness among Indians about these traditional therapies. The growth in Spas in India is also luring the travelers to visit some non-visited corners of India. This has however led to competition with Indian traditional healthcare systems, in the domestic as well as in the international scenario. 5.2.12 Social Competition Weeding Out of Quacks. The Ayurvedic massage centers have been attracting a lot of western tourists to the country; however, the non-intensive regulatory framework has allegedly brought-in a flood of quacks into the industry. Growth of such quacks may kill the industry as untrained newcomers may cause more harm than good. Kerala, the most enthusiastic promoter of Ayurveda has been seeing hundreds of practitioners who have been taking advantage of the growing popularity of the ancient healing medicine and almost every big hotel boasts of Spa or Ayurvedic treatments.

5.3 STRATEGIES
5.3.1 Policy Level Prescriptions 5.3.1.1 Focussing on In-Country Healthcare Experts opine that quality healthcare along with faster healthcare delivery is vital for improvement in healthcare indicators of any nation. Healthcare tourism can only be promoted in India through increasing the reputation of India as a country for cleanliness and health-orderliness. No travelers would be interested to visit a country, even just for tourism / vacation purpose, if there is prevalence of communicable diseases in the country. Our competitiveness as low cost healthcare destination will be eroded if the national healthcare indicators are considered to be lower than other countries. Thus, it is important to focus on in-country healthcare to create positive perceptions about India as a healthcare destination.
166
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

In order to rise the overall health situation in India, we need to set up universally acceptable healthcare system with adequate quality that would grow along with the future healthcare demand. This would call for better-defined policies to attract significant investments in this sector. In addition, associated activities such as research and development, human resources development are required to ensure realization of equitable and efficient healthcare system. There are suggestions from experts to mobilize funds for improving in-country healthcare in India. One such suggestion is to levy a cess on the healthcare tourism revenues of private hospitals / airlines / hospitality services industry, on the lines of the current levy of education cess. Other suggestions include increasing the role of healthcare tourism service providers (especially the hospitals) to cater to the nations rural healthcare, by way of setting up of hospitals in remote areas or provision of healthcare services through the concept of telemedicine.

5.3.1.2 Define and Enforce Minimum Standards for Healthcare Facilities At the institutional level, healthcare organizations / wellness centers need to provide sophisticated facilities to improve the quality and overall experience of the patients. This should be supported by the brand-building efforts at government level, seeking accreditation and mutual recognition of standards.
Standards and associated quality in service are some of the priority areas for the international healthcare tourists. There have been cases of warnings and outcry in several developed countries doubting the quality of healthcare services offered in developing countries and likely post-operative complications. Healthcare insurance coverage may also be difficult if the hospitals do not meet the required accreditation standards. Thus, it is important for Indian healthcare providers to benchmark themselves vis-a-vis the hospitals in developed countries as also with the competitor countries on various quality parameters. The hospitals can position themselves advantageously through achieving international accreditation standards, streamlining the processes and displaying consistency in performance.

167
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

The concerns of international travelers, with regard to procedures for infection control in the hospital, laboratory and radiology services, dispensing the medicines, policies for proper monitoring of patients health during surgery or when in anesthesia, waste-management, will be minimized when they avail treatments in internationally accredited healthcare establishments.

5.3.1.3 Need for a Composite Healthcare Tourism Policy Government of India has announced, in 2002, a National Health Policy and a National Tourism Policy. While some references have been made in the National Tourism Policy with regard to Indias potential to tap the tourism market using its healthcare skills, including the traditional wellness systems, there is a requirement of specific policy focusing on promotion of healthcare tourism, clearly identifying the roles of various segments of players. This would require coordination between the two major government departments, viz. Tourism and Health. Consultations may also be necessary with other departments / agencies / organizations such as Ministry of External Affairs, Immigration Department, Tourism Promotion Organisations, State Governments, Indian Healthcare Federation, Associations of Travel Agents, Tour Operators and Hotels. 5.3.1.4 Stimulating Investment in Healthcare Infrastructure In the absence of an appropriate social health insurance, the only option available for insuring the poor against health-associated risk is by providing good quality care in the public hospitals. This would require sizeable investments for strengthening, upgrading and expanding the public health infrastructure in India.
Further, experts have opined that India needs to transform itself from an illness-based healthcare model to a wellness-based model, wherein healthcare is linked to improving sanitation standards, health awareness, availability of safe drinking water and nutrition. The wellness model, which is linked to so many associated socio-economic indicators, require significant funds, and the onus lies equally on the private and public sectors to work out innovative models leveraging the respective strengths.

168
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

The governments role as a purveyor of primary healthcare as also its role in improving the national health indicators should be reiterated through increase in governments budget for health related expenditures. Estimates52 have placed an additional investment requirement (by the public sector) of Rs. 75,000 crores to bridge the demand supply gap (Table 14). Adding to the current level of public health expenditure, this totals out to around 3% of GDP. Such an initiative would also attract players from the private sector to increase their investment levels and undertake additional initiatives to achieve the common goal. Active participation by private sector may be encouraged through benevolent tax structure and fiscal incentives. It would be relevant to promote a healthcare development mission with an appropriate model that not only improves access to healthcare in rural India but also enables the private sector to have viable investments. The concept of telemedicine should be promoted in an attractive manner in order to make more number of players to participate. Private sector may also come up with models under the umbrella of CSR (corporate social responsibility) that would support the governments initiatives in increasing the healthcare indicators. Industry53 estimates have put the total investment requirements (both from public and private sector) for Indias healthcare sector at Rs. 912,000 crores (or over US $ 200 billion) by 2012.

5.3.2

Stakeholder Level Prescriptions

5.3.2.1 Government / Industry Level a) Technology Upgradation The quality of healthcare delivery is also aptly supported by technological solutions, and investments in software and cutting edge equipments such as MRI, Gamma Knife machines. Software applications would be required to undertake molecular diagnostics,

Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, August 2005
53

52

Federation of Indian Chamber of Commerce and Industry;http:// www.ficci.com/press/217

169
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Table 14: Additional Investment Requirement from Public Sector for Healthcare Improvement in India (Rs. Crores)
Category Total Estimated Amount Required (Rs. Crores) 4000 1332 9936 1618 4000 44928 Capital Revenue / Year % of Total Revenue

Health Promotion Regulatory Systems Human Resources for Health Training R&D Delivery of Services Social Insurance for Secondary care and Upgradation of Secondary Hospitals Total

443 7796 853 750 23969

4000 889 2140 765 3250 20959

10.00 2.00 5.00 3.00 8.00 50.00

9003 74817

33811

9003 41006

22.00 100.00

Source: Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, August 2005

and to assess risk and treat diseases leveraging pharmacogenomics and regenerative medicine. Several healthcare centers in developed countries have created portals for patients that help towards greater patient involvement in their healthcare delivery. Such portals have features such as online interaction with doctors, self-scheduling of appointments and access to medical records. Several studies have demonstrated that use of cutting edge technologies and leveraging of IT in healthcare delivery are likely to increase the productivity. Computerised patient records, enabled with alert / reminder systems for administration of medicines / diagnostic tests or monitoring of patients have proven to be improving the patient care, healthcare outcomes and help in reduction of costs. Since the hospitals in developed countries have
170
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

greater level of technological leverage, and the foreign patients are accustomed to a number of comforts leveraging the technology, Indian hospitals need to address the issue of upgrading the technology, so that the visiting patients feel at ease.

b) Create Cost Effective Facilities Low cost solutions are the prime driver of flow of healthcare tourists towards developing countries, such as India. Hence, it is important for Indian players to remain cost competitive, vis--vis other developing countries, while improving the quality of healthcare services, leveraging technology. Tie-ups with different players of healthcare or tourism segments would help in offering cost effective facilities. In addition, outsourcing of medical logistics in major areas like housekeeping, food and beverages, diagnostics, supply of
Box 23: Role of Export-Import Bank of India

Export-Import Bank of India (Exim Bank) is a wholly government-owned financial institution, set up for the purpose of financing, facilitating and promoting Indias trade and investment. The mission statement of the Bank is to develop commercially viable relationships with externally oriented companies by supporting their internationalization efforts, through a diverse range of products and services. The Bank offers a diverse range of financing services for the Indian exporters, including a variety of export credit facilities, and finance for export oriented companies. The Bank also supports services sector, with special focus on entertainment, healthcare, hospitality and shipping. The Bank has a comprehensive programme in terms of equity finance, loans, guarantees and advisory services to support Indian outward investment. Besides, on select basis, the Bank also undertakes direct equity stake in Indian ventures abroad, to enable Indian companies to supplement their equity contribution. The Bank intends to play a greater role in supporting healthcare and healthcare-tourism associated projects in India and abroad to enable Indian companies to provide healthcare solutions to the needy population in the world.
171
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

medicines / medical equipments and other process services including medical coding, billing, claim processing and transcription would bring down the cost significantly. Such measures would also pave the way for concentrating in the core activity of patient care by the hospitals.

c) Facilitate Adequate Supply of Quality Manpower Health care is a labour-intensive service industry. Hence, development of quality healthcare workers as also motivating them is one of the essential components for achieving our national healthcare objectives. It may thus be emphasized that, more than mobilization of monetary resources, to meet the investment requirements of the healthcare system, it is important to address the issue of shortage in healthcare human resources in India. Another reason for shortage of healthcare professionals in domestic market is international mobility of professionals. In addition, there is also mobility of skilled personnel from public sector hospitals to private sector, which imbalances Indias healthcare system.
In order to cope with the demand for healthcare professionals, it is necessary to increase the number of medical colleges and nursing schools in India. Further, it is also essential to increase the intake of students in healthcare educational institutions, devising schemes that would bring back the serving Indian healthcare personnel to home country, and reemployment of retired health personnel. Quality supply of healthcare professionals may be ensured through improvements in standards of training, especially in paramedical educational institutions. The National Commission on Macroeconomics and Health, set up by the Government of India, has recommended for establishing an institutional framework for human resources development and medical and health education with the objective of promoting excellence in healthcare and human resources for health. The institution may also be empowered to set standards of training, design courses relevant for the health needs, standardise and upgrade curriculum and undertake the integrated planning and development of human resources in health sector, and to establish a system of accreditation of training institutions.

172
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

d) Role of Continuing Education The concept of continuing medical education would help the healthcare professionals in updating themselves on the emerging trends in medicine and the ethical issues involved. Many developed countries have continuing education programmes for healthcare professionals. Some universities / institutions abroad have established online continuing education programmes that would help the healthcare professionals to update themselves on emerging medical trends. In India, the Apollo Hospitals Group has established the concept of Medvarsity a virtual classroom for continuing healthcare education. Such initiatives may be strengthened with the active involvement of government departments, professional bodies.
It is further suggested that there should also be a system of re-registration of healthcare professionals including doctors and nurses with a minimum number of hours of continuing medical education. Few developed countries (such as UK) have such reregistration systems that help the healthcare professionals to keep abreast of the latest advancement in their respective specialties.

e)

Leveraging the Potential and Popularity of Indian Wellness Systems India has been using its rich biodiversity in the healthcare segment for over four thousand years through the traditional systems of medicine. The countrys rich traditional experience and wisdom is ensconced in wellness systems such as Ayurveda and Yoga. India has also documented the traditional systems of medicine and has abundant indigenous supply of roots and herbs.
Indian wellness systems are gaining a growing attention and acceptance all over the world. India, however, needs to strategically leverage the popularity of its wellness systems while offering healthcare services to travelers. Such an approach would provide huge growth opportunity for healthcare tourism industry in India. Indian hospitals as well as hotels could promote classical Ayurveda treatments such as Pachakarma (five basic cleansing methods), Navarakizhi (rice bundle massage), Ilakizhi (leaf bundle massage) Dhara (continuous pouring of medicated oil), Pizhichil

173
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Box 24: Concept of Medvarsity

Medvarsity, under the joint initiative of Apollo Group, NIIT Ltd and global leaders in e-learning solutions, was established in April 2000 as Indias first virtual medical university to provide complementary medical education using information technology. Medvarsity provides world-class solutions and expertise in areas such as IT in medicine, standardization of education, knowledge management, efficient evaluation systems, contemporary curriculum, exposure to recent advances, and digital library resources. Medvarsity has already entered into MOUs with four medical colleges and has nearly 1400 medical students and doctors registered on its platform. Medvarsity has about 5000 hours of quality content and is in the process of acquiring more. Medvarsity courses are even recognized by the Royal College of General Practitioners, U.K. The content is organized, structured and web-enabled in various forms including audiovisual lectures, multimedia textbooks, procedural videos, interactive learning tools, clinical case reviews, and clinical updates. Medvarsity complements the existing medical education infrastructure by providing a dynamic network of various medical colleges across the country. It enables students, faculty and practitioners to participate in the virtual classroom, where they can interact with the global peer community and have access to knowledge, resources and techniques cutting across geographical barriers.
Source: Apollo Hospitals Group; www.medvarsity.com

(oil bath), Abhyangam (general massage), and Swedanam (treatment to remove toxins from body) as preventive healthcare for the international travelers (both business and leisure). Similarly, potential exists to offer healthcare solutions through Yoga in hospitals, hotels and wellness centers. Some of the Ayurvedic treatments could be offered independently on the lines of Thai Spas.
174
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

f) Market Segmentation of Healthcare Skills Healthcare tourism is a unique segment of the tourism market where customers have very complex and specific needs. In order to provide customised products / services, market segmentation is necessary for understanding the diverse requirements of customers from various countries and regions.
Travellers from countries such as UK and Canada, where the national healthcare system is a predominant service provider, could be targeted to cater to the needs of cosmetic care, as in these countries the national healthcare system supports only critical care needs. Such treatments would also be of interest to travellers from USA or other European countries, where commercial healthcare insurance do not cover such treatments. Top surgical and nonsurgical cosmetic procedures undertaken by Americans in 2006 is given at Annexure 7. Cosmetic treatments such as hair restoration, rhinoplasties, eyelid surgery, cosmetic surgery for
Exhibit 26: Model for Cross-selling Various Strengths to International Tourists

Source: Exim Research

175
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

facelift, breast augmentation/ reconstruction, and liposuction are generally undertaken through less-invasive surgical procedures, and therefore require limited follow-up care. Thus potential exists for suitably packaging leisure tourism or traditional wellness systems along with cosmetic treatments. A model for cross-selling of Indias various strengths to international tourists is depicted in Exhibit 26. Similarly, in some countries (such as UK and Canada) where the national healthcare system meets the healthcare requirements of the citizens, there is a long waiting list even to undertake emergency procedures. These include cardiac care / surgery, renal surgeries, joint replacement, neuro-surgery, trauma-surgery, eye care / refractive surgery, vascular surgery. Since these treatments are expensive, the non-insured population from USA and Europe could also be another target segment. Patients from Middle East, Africa and South and South East Asia travel to India seeking hi-tech treatment procedures that are not available in their country. These include preventive healthcare / diagnostics, gynaecology and obstetrics, dental care, infertility, osteoporosis etc. In addition, India should actively pursue niche markets using its popular wellness systems such as Ayurveda and Yoga, and telemedicine services to differentiate itself from the increasingly competitive market landscape. Market segmentation of Indias healthcare skills is depicted in Exhibit 27.

g) Creating Networks for Brand Generation It is essential that the Governments (both central and states), industry associations as also the corporates to build appropriate networks across the world with relevant stakeholders. The Government could play a major role in brand creation for Indian wellness systems that have started attracting international travelers. This includes common branding of India as a safe, scientifically advanced and cost effective center for healthcare tourism. The Government also has a role in negotiating with its counterparts for recognition of mutual standards and systems, as also for coverage of healthcare expenses incurred in India by the international patients, under the respective national healthcare systems.
176
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 27: Market Segmentation For Indias Healthcare Skills

Source: Industry Inputs

At present, tourism offices of Government of India is playing a major role in provision of adequate information with regard to various tourism themes being propagated by India as holiday ideas. These include adventure, Ayurveda, backwaters, jungles, beaches, diving, citylife, eco-tourism, healthcare tourism, hill stations, pilgrimage, palaces, deserts and heritage. In addition, circuits are also being promoted be it religion or region oriented. These include: the golden triangle, Buddhist circuit, temple trails, Punjab circuit, and the North-east circuit. The promotional efforts of India tourism offices abroad could be strengthened leveraging the presence of Indian Missions / Posts, airline offices (Indian operators) abroad and offices of foreign airlines in India. Government, in association with the players in the healthcare and tourism industry, should adopt the Hub-Spoke-Rim (HSR) Model
177
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

to promote the circuits, leveraging the flow of healthcare seekers from various countries. For example, Buddhist circuit could be clubbed with spiritual healing or Yoga being promoted by state Government of Uttar Pradesh. The Golden Triangle could be clubbed with seekers of treatments in multi-specialty hospitals. In addition, minor tourist places could also be covered while promoting through such HSR model. Picotiral presentation of HSR model is given in Exhibit - 28.

h) Greater Level of Public-Private Partnership Promotion of healthcare tourism is not the sole responsibility of either the Government or the private sector; it should be promoted through a well-defined partnership between the Government and industry. However, different countries have adopted different models with greater degree of public / private sector role in promotion of healthcare tourism. Development of healthcare tourism is more government driven in Singapore and Malaysia, where the industry develops out of a planned context to boost the tourism industry in the country54. Whereas, in Thailand and India, the healthcare tourism industry is more private sector-oriented with corporates making their own strategies to promote the country as healthcare destination. A model for promoting healthcare tourism through public-private partnership is depicted in Exhibit 29.
The government has an essential role in development of regulatory framework for the healthcare services trade. The regulatory framework includes segments such as medical/paramedical education, accreditation of healthcare establishments, quality and standards, insurance and investments in public health. Through enabling policies, the Government should promote investments in healthcare and ensure that the national healthcare indicators are improved to create an international branding and thereby pave the way for international healthcare tourism. The facilitative role of the Government, through appealing incentives would help improve the healthcare infrastructure in the country. The private sector (the tourism, insurance and healthcare segments independently and collectively) on the other hand would
Bennett Yim & Phoebe Ho, Healthcare Destinations in Asia, Asia Case Research Centre, University of Hong Kong; 2005
54

178
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 28: Hub-Spoke-Rim Model for Healthcare Tourism

Source: Exim Research

undertake corporate initiatives to increase investments in healthcare tourism infrastructure and project their capabilities abroad.

i) Role of Government Significant achievements have been attained by the Indian corporate sector in development of healthcare tourism industry in India. However, the role of Government is important, as promoter, regulator and facilitator, for strengthening the initiatives of private sector. The Governments role as a facilitator may be emphasized through provision of information, easier immigration procedures, strengthening of infrastructure, and provision of financial incentives to the players of the industry. The regulatory role of the Government should ensure in setting treatment standards, monitoring the patient safety standards and quality of services. The Government may also play a promotional role in announcing a healthcare tourism policy that would help implement national healthcare missions. The
179
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Exhibit 29: Public-Private Partnership Model For India to Promote Healthcare Tourism

Source: Exim Research

promotional role would also include aligning resources, harnessing knowledge, and seeking international cooperation to project India as a healthcare destination. Diverse roles of the Government for development of healthcare tourism industry is depicted in Exhibit 30.

j) Regional collaboration Experts have opined that, as in the case of general tourism, healthcare tourism also benefits significantly if cooperation is extended between countries of a region / bloc. The cooperation may be in the form of education, recognition of curriculum, exchange of professionals, experience sharing through training programmes, joint marketing and promotional campaigns. Regional cooperation should also lead to pooling of resources and joint development of products and services to attract healthcare tourism flow into the region in general and cross country tourism flow in particular.
Some of the Latin American countries, such as Cuba, Costa Rica and Colombia, who are increasing their interest in the healthcare tourism business, are actively formulating regional cooperative networks and joint marketing strategies. India may consider adopting such regional cooperative framework with Asian countries, such as Thailand, Malaysia, Singapore, Philippines, Sri Lanka, to increase the regional competitiveness in healthcare tourism business.
180
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 30: Diverse Roles of Government for Development of Healthcare Tourism Industry

5.3.2.2 Firm-level Prescriptions a) Non-Medical Services In addition to world-class healthcare services, the establishments are expected to provide non-medical services to the international travelers, who look forward to a total consumer experience. Nonmedical services that may be provided by the hospitals as single channel may include logistic arrangements such as air travel, stay and local transportation, translation, suggestions on tours/ sightseeing and the arrangements, outlet for food and beverages for the accompanying persons, and other services that may be expected from a hotel or airline operator.
Many healthcare establishments abroad, both in developed and developing countries are increasingly concentrating on provision of non-medical services to attract international patients. In order to cater to the requirement of non-medical services, hospitals need to tie-up with key partners such as hotel chains, tour operators, and airlines industry. The tie-ups may be by way of facilitating the partners to set up an extension counter in the premises of the hospitals, or to train the staff of the hospitals in catering to such services, or to avail / provide the services on sub-contracting basis. Once tie-ups are established for various non-medical services, healthcare establishments could market the healthcare solutions in a composite manner as a single package. It may be emphasized that healthcare establishments need to learn the skills from the hospitality industry through such tie-ups.

181
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

b) Standards Based Price Banding Efforts are being taken by the industry, through the Indian Healthcare Federation (IHCF), to work out an indicative uniform price banding of various specialties. In its publication55, IHCF has compiled the price banding of various healthcare packages under select broad categorization. These include cardiac packages, minimally invasive packages, therapeutic endoscopy packages, orthopedic packages and oncology packages. While these are indicative packages, the patients should get details related to the categorization of standards of various healthcare establishments vis--vis the prices. This would call for standards-based payment systems, which would help enforce the quality in services and provider accountability. c) Change from Hospital Centric Approach to Patient Centric Approach All over the world, with the objective of reducing administrative costs and thereby to offer healthcare services at minimal cost, hospitals are going towards patient centric systems in which the patients well-being and the responsibility for his or her own good health are defining treatment and operational policies. Such an approach reduces the cost of premium on liability insurance for the hospitals or malpractices insurance for the doctors.
However, under a patient centric system individuals have the right to expect improved care as long as they educate themselves about health maintenance and wellness practices, change their behaviours to better manage their health, access medical records and information and contribute towards an appropriate share in total cost56. This switchover is being possible leveraging the technological advancement. Characteristics of patient-centric approach is depicted in Exhibit 31.

55

India The Global Healthcare Destination, Indian Healthcare Federation

56 Patient Centric The 21st Century Prescription for Healthcare and Life Sciences, IBM, May 2006.

182
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

Exhibit 31: Characteristics of Patient-Centric Approach

Source: Exim Research

d) Adhering to Patient Safety Norms Many studies have opined that weak systems lead to errors and mistakes in high-risk segments of healthcare services. The weak systems may include lack of clear protocols for treating patients, low level of knowledge and experience amongst downstream / paramedical staff, fragmented patient information and low level of coordination. While these are issues that already prevails in a weak healthcare systems, adding tourism / leisure services to the patients weakens the system further.
A completely risk-free environment may not be attainable in healthcare tourism. However, the risks can be significantly reduced if proper patient safety norms are devised and adopted while providing services. Both, healthcare and tourism industry need to jointly chalk-out patient-safety norms to minimize the risks involved. Three core areas and performance requirements are suggested in Exhibit 32. It is also important to ensure that patient safety is a key component of educational curricula, training programmes and induction schemes for the professionals of both healthcare and tourism industries.

e) Negligence Reporting System Provision of healthcare is a complicated, high profile and risky service. The degree of complication or risk profile may vary with
183
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Exhibit 32: Three Pronged Strategies for Ensuring Patient Safety in Healthcare

Source: Exim Research

the specialty / procedure administered. While there will be certain amount of inherent risk associated with healthcare procedures, the risk profile gets compounded by the potential for errors at various stages, including post-operative care. Several studies have observed certain number of adverse events even in developed countries where systems and procedures are in operation. A Harvard University study57 indicated that about 4 percent of hospital admissions in USA have seen adverse events. Another study58 had shown even a higher incidence of adverse events at 16% in Australia.
57

Brennan T A, et al., Incidence of Adverse Events and Negligence in Hospitalised Patients, Results of the Harvard Medical Practice Study, The New England Journal of Medicine, Volume 324, February 1991. Wilson R M, et al., The Quality in Australian Healthcare Medicine, November 1995
58

184
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

It is believed that the increasing risk profile could be contained with a proper negligence reporting system that helps improve the learning / correction process. In India, though we have instituted a negligence reporting system under the Indian Medical Council, there has been no voluntary reporting (of their own errors) by the doctors / hospitals. It is essential to have a legislation enforcing the healthcare establishments and doctors to report adverse incidents in their own interest. An ideal reporting system should also have a balance between the roles of public accountability and learning from errors. Similarly, the reporting system should not accommodate illegitimate reports that are served with the purpose of economic, political or social reasons. It is also pertinent to understand that reporting systems alone will not be sufficient to improve the healthcare quality. Data generated out of such reporting systems should be analysed to identify areas for improvement. Guidelines and protocols should be developed to minimise errors in the identified areas. Several states in USA that have instituted reporting procedures for adverse incidents in the hospitals, use the data generated out of the system in a constructive manner to improve quality and reduce adverse events.

f) Intensive Marketing and Promotion The corporate sector also has a major role in creation of individual corporate brand image. Already few corporates such as Apollo, Fortis, Wockhardt and Max have created their individual brand names in overseas markets by way of establishing patient facilitation centers and marketing tie-ups. One promotional model could be direct marketing to patients, as the patients are increasingly learning more and more about their illness and getting familiarised with the treatment options. An interactive website with transparent information on facilities, non-medical services, schemes and prices would help reach to the potential healthcare tourists on a continuous basis. In addition, depending on the target countries, the marketing platform could be customized viz., through the referral doctors, hospitals, insurers, medical tourism agencies, as also through governments / corporates (for catering to the citizens / employees healthcare).
185
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

Box 25: The New York Patient Occurrence and Reporting and Tracking System

In USA, several states have instituted reporting procedures for adverse incidents in hospitals. New York State, for example, seeks the hospitals to report adverse incidents (both unexpected outcomes and bad errors) under a system called New York Patient Occurrence Reporting and Tracking System (NYPORTS). NYPORTS is a collaborative system of hospital industry, consumer advocates, and medical specialists. The data generated out of such a system is used for issue of healthcare advisories, news and alerts, as also for surveillance activities by the Government. The data helps the healthcare establishments to compare themselves with peer groups, and plan quality improvement initiatives.
Source: Department of Health, State Government of New York; http:// ahcpr.gov/news/ulp/ptsafety/ptsafety7.htm

Players also need to enlarge their geographical reach through physical presence abroad. Popular hospitals in Thailand, Malaysia and Singapore are establishing representative offices in other countries to help establish and maintain relationship with local hospitals, travel agents, insurance agencies as also the government departments. Participation in trade shows, exhibitions or health symposiums / workshops would allow the players to showcase their expertise. The corporate sector should strengthen their focus on tie-ups with healthcare establishments and accreditation agencies across the world for knowledge transfer and recognition of quality in deliverables. In addition, tie-ups with healthcare tourism operators abroad are also essential. Few hospitals have already established tie-ups with renowned healthcare tourism operators abroad such as Planet Hospital, Med De Tours and Taj Medicals for offering of packaged services and smother facilitation of international healthcare travel. The healthcare tourism operators publicise the comparisons of the cost of treatment offered in India vis--vis other

186
C M Y K

C M Y K

Opportunities, Challenges and Strategies for India

countries such as UK in a transparent manner. The operators also provide value added services such as travel arrangements, visa processing, facilitation of patient-doctor interactions. Such collaborative efforts offer more value to the healthcare travelers, in addition to driving the tourism traffic to India. However, such strategies have to be strengthened to have greater geographic reach.

g) Leveraging Traditional Systems of Medicines Another strategy would be to leverage the traditional systems Yoga, Ayurveda in the healthcare tourism promotion campaigns. Thailand has been successfully leveraging its alternative therapies and Spas for promotion of tourism. In addition, Indias culture, hospitality and strong traditions could become major selling points to attract tourists. Opportunities also exist to link the healthcare services with other tourist activities such as ecotourism, rehabilitation, educational and business travel. A list of major forms of traditional medicine practised in the world is given at Annexure 8. h) Transformation of the traditional systems to suit international domain. The traditional systems of healthcare, such as Ayurveda and Yoga could be transformed to suit the new international domain, wherein science-based evidences are being sought. Innovations are being undertaken and professionalism is being introduced. Such strategies could be strengthened further in order to attract more international customers.
There have also been instances of healthy collaborations of traditional knowledge systems with modern medicines. For example in some cases, heart patients with acute problems undergo a surgery and then during the recovery period their treatment is supplemented with the use of Ayurvedic or Yogic solutions. Similarly in the case of Asthmatic patients, Yogic exercises and dietary restrictions can help in speedy recovery. Convergence of traditional healthcare solutions Yoga along with Ayurveda is also increasingly becoming popular to attract international customers, who are familiar with one system and to introduce the benefit of other.
187
C M Y K

C M Y K

Healthcare Tourism: Opportunities for India

i) Professionalisation of the traditional healthcare domain The production and distribution of Ayurvedic and traditional systems of medicine has been increasingly modernized over the last few decades and it has been organized along modern lines to cater to the needs of the new-age patients. Manufacturing firms of Ayurvedic medicines in India generally believe that the ideal healthcare system lies in the synergy between Ayurveda and Modern medicine. Such firms are increasingly producing a wide range of products categorized under pharmaceuticals, which include formulations for health maintenance, eye, cardiac care; personal care products such as oral care, skin care, hair care; and animal healthcare products.
In China, there has been a successful integration of Chinese medicine with modern medicine and this has resulted from the fact that medicinal herbs are synthesized using modern techniques. In fact, medical students in China have to now take up courses both in western and traditional medicines. This cross-cultural knowledge has been actively implemented in hospitals and educational centres. When they are given the opportunity to learn from both western and traditional methods, they get to know the advantages and disadvantages of both these methods. This will help them in bringing about the fusion of the best of both the methods and provide better results. This strategy can be adopted by India for further development.

j) Adoption of success strategies followed in other countries India could tap significant opportunities in the growing international healthcare tourism by way of developing its healthcare systems, using the successful strategies adopted in other countries. The model developed by Thailand in popularizing the Thai Spas, or the model adopted by Singapore, through enabling statutes to encourage transplantations, or the model adopted by China in popularizing the Chinese medicines, or the model adopted by Malaysia to combine the healthcare with tourist destinations, or the combination of all the above, could position India as an ideal healthcare destination. Convergence of traditional healthcare solutions with modern medicine would also encourage international travelers to visit India for their wellness requirements.

188
C M Y K