Are we ready for medical tourism?
RUPA CHINAI and RAHUL GOSWAMI
The private healthcare industry is quietly facilitating a revolution to enable India to emerge as a health destination. Yet there are the sceptics.
`Nearly 82 per cent of all health spending in India is private.' World Bank study
PHOTO: VIVEK BENDRE
CONFIDENCE INSPIRING: A patient from West Asia at Mumbai's Jaslok Hospital.
STARK contrasts are no surprise in urban India, and in the healthcare sector, the difference between what is available (world-class techniques and service, at a price) and what the common denominator urgently needs is no less so. In Mumbai, as in New Delhi, Chennai and Hyderabad, private sector healthcare centres are gleaming "islands of excellence", as the industry calls them, all too often surrounded by seas of medical neglect.
These "islands" the private healthcare industry in India are quietly facilitating a revolution. Only seven years from now, the most optimistic industry forecast posits, medical tourists hosted by India can pump Rs. 10,000 crores into our economy. An estimated 1,50,000 such visitors a year already spend about Rs. 1,500 crores in India for treatment.
When the mix is just right (support from the government in the form of incentives and tax breaks, international healthcare accreditation standards in place, breakthroughs in insurance coverage for overseas patients, and savvy promotion of India as a tourism-plus-medical tech destination) the sector is certain the numbers will fall into place.
What's more, the beneficiary of such growth will be the country's desperately overburdened public health system, say industry associations such as the Confederation of Indian Industry (CII) and the Federation of Indian Chambers of Commerce and Industry (FICCI), which see medical tourism a mirror of the early years of India's info-tech growth.
Explaining the view, Anupam Verma, honorary secretary of the Medical Tourism Council of Maharashtra and a director of Mumbai's Hinduja Hospital, says, "Look at the possibility of the public hospitals being technologically upgraded to world-class standards with this source of income. Also, with exposure to the paid medical service market, the spirit of competition will germinate in public hospitals ...(to) enhance their efficiency and service delivery levels."
Such optimism apart, India's three-tier public health system primary health centres (PHC) in villages, district hospitals, and tertiary care hospitals is increasingly unable to attend to the medical needs of the population.
Government expenditure on public health infrastructure is shrinking. At present, India spends about a per cent of its gross domestic product (GDP) on healthcare, lower than the average of 2.8 per cent of GDP spent by some less developed countries.
Yet, as the National Human Development Report (2001) points out: "There has been a misplaced emphasis on maintenance and strengthening of private health care services ... at the expense of broadening and deepening of a public health care system targeted at controlling the incidence of disease, particularly of communicable diseases, in rural areas."
Private healthcare is indeed expanding rapidly to fill the need for services. According to a World Bank study released in January 2004, nearly 82 per cent of all health spending in India is private.
PHOTO: R.V. MOORTHY
A WIDENING GAP: Can public healthcare catch up?
The study also pointed to health inequities such as the poorest quintile getting only 10 per cent of subsidies, while the richest 20 quintile captures 33 per cent.
Jean Dreze of the Delhi School of Economics calls it a "paradox". Bed capacities in five-star private hospitals remain under-utilised, he has observed, forcing the industry and government to promote health tourism, and "on the other hand, PHCs are suffering due to lack of government patronage".
Dr. Nergis Mistry, scientific researcher with the Foundation for Medical Research, Mumbai, warns against a technology and urban-centred approach to delivering healthcare. "Medical tourism will force us towards the latest expensive technology that is demanded in the West," she says. Mistry believes that a technology-centric approach to healthcare, such as that promoted by the major private hospitals, will inevitably affect the cost of care to the common man.
Given the fiscal imperatives (healthcare is also an industry, after all) how does the private sector in India propose to make services accessible and affordable to the average Indian, and how does the private sector define its responsibility to public health care?
"The role and responsibilities of the government are clearly in the areas of primary healthcare, epidemics, public health and sanitation," says S.K. Venkataraman, chief financial officer of the Apollo Hospitals Group, "whereas the private sector can cater to secondary, tertiary and quaternary care and the increasing burden of diseases due to lifestyle factors, like cancer, cardiac ailments and diabetes."
Dr. Naresh Trehan, executive director of the Escorts Heart Institute and Research Centre, says the private sector can "contribute in small but significant ways given its resource constraints".
Escorts runs a rural healthcare programme under which it deputes specialists to conduct cardiology camps that examine patients free of cost, he says. Villages are "adopted" to "improve their basic levels of sanitation and health and awareness, which goes a long way towards improving the health index", Trehan adds.
But, what does medical tourism promise to deliver and why is the public sector not convinced? The dream of a million medical tourists, establishing India's status as a health hub and boosting an industry to growth rates rivalling that of info-tech, is seen as within reach by the private sector.
In the last two years, international news coverage of India's major private hospitals Apollo, Asian Heart Institute, Escorts, Fortis, Hinduja, Max Healthcare, Wockhardt and Woodlands among them has been upbeat and confidence-inspiring. At home, however, the question increasingly being asked by public health practitioners is: how will this affect the country's health indices?
The numbers that the industry can offer are internationally tempting, and not only for United States or United Kingdom-based patients. Heart surgery that would cost $30,000 (or approximately Rs. 12,90,000) in the U.S. or Britain costs approximately $14,000 (or Rs. 6,02,000) in Thailand (a major destination for medical tourists) and around $7,000 (or Rs. 3,01,000) in India. A bone marrow transplant procedure would run up a bill of $2,50,000 (or Rs. 1,07,50,000) in the U.S. or Britain, versus $60,000 (or Rs. 25,80,000) in Thailand and $30,000 (or Rs. 12,90,000) in India.
Despite these numbers, regional competition for medical tourists is fierce. Thailand is currently the Asian leader both in number of foreign patients and revenue. Malaysia and Singapore too have set in motion aggressive plans, with ambitious targets, for the years 2010-12, which is also seen as a defining period by CII and the Indian Health Care Federation (IHCF), an association of about 60 hospitals.
Now, private healthcare groups are lobbying for the adoption of measures they say will encourage growth some of these are tax allowances for rural doctors, relaxations in the norms for setting up medical colleges, and relaxation in indirect taxes on purchase of equipment, medicines, medical consumables and devices.
"The challenge," says Dr. Trehan, "is to try and match the cost of creation with ability to pay. Thus to incentivise hospitals to come up in rural areas, the government needs to go much beyond this."
S.K. Venkataraman emphasises that the industry urgently needs infrastructure status "with attendant benefits like a tax holiday, concessional utilities and preferential land allotments, in order to create an enabling environment for the healthy growth of this sector".
These demands are questioned by health policy analysts. Ravi Duggal, health researcher with Mumbai's Centre for Enquiry into Health and Allied Themes, points out that private hospitals have obligations for their not-for-profit status under the Public Trust Act to provide healthcare free to the extent of 20 per cent of their resources. "Where is the accountability of this provision?" he asks.
Certainly, the view from ground zero of a public hospital's out-patient's department is uniformly grim. Under-funded, undermanned and under-equipped, Mumbai's severely overburdened public hospitals have borne the brunt of public rage.
`Will make no difference'
Dr. K.C. Ojha, financial director of the Bombay Hospital for 27 years (until 1994) says bluntly: "Medical tourism will not make any difference to Indian healthcare. It will mean greater profits for the private hospital sector and creation of Indian jobs. Hospitals that provide for medical tourism will not create subsidised treatment for Indians."
He is alarmed by symptoms of the widening gap between medical need and service in the second half of 2004 there were at least seven reported incidents in Mumbai of patient's families assaulting hospital staff, both in State and municipal corporation-run hospitals, and private clinics, because of the perception that they were victims of medical negligence. "Their anger is spilling over in assaults on doctors, unheard of until now in a country where the medical profession is worshipped next to God," says Dr Armida Fernandes, former dean of the State government-run Sion Hospital in Mumbai.
With charges for speciality services steadily rising, healthcare moves out of the reach of the common man, she adds, often propelling them into either indebtedness or to quacks.
Nevertheless, Dr. Nilima Kshirsagar, dean of the King Edward Memorial Hospital in Mumbai, sees the possibility of leveraging the expertise and experience teaching hospitals have in clinical medicine and surgical skill.
"With augmented infrastructure we can provide services to foreign patients and revenues earned can subsidise poor Indian patients," she says, which is a view close to that of the CII and IHCF.
The bottom-line for Kshirsagar however is equity: "People are looking at health as a business. The government has not examined how our patients will benefit from medical tourism or whether they will lose out. The need to benefit Indian patients is the main goal, and medical tourism cannot be at their cost."
CHENNAI's Frontier Lifeline Hospital (Dr. K.M. Cherian Heart Foundation) began healing the hearts of international patients on March 1, 2004.
PHOTO: VINO JOHN
ALL'S WELL: In Chennai.
"They were treated free of cost," says Dr. Cherian (in the picture, first row sitting, fourth from right). "That's when the foreign patients started coming in. Chennai is truly the health hub of Asia." Over the course of a year, Frontier Lifeline has seen more than 200 patients from Fiji, Iraq, Kenya, Malaysia, Mauritius, Palestine, Tanzania and Uganda.
In the first year of operations, Dr. Cherian says Frontier Lifeline generated $2,00,000 (or approximately Rs. 86,00,000). "If a small place like this can earn so much foreign exchange, imagine if we built dedicated health hubs with all the facilities."
Surgical procedures that cost upwards of 3,000 (or approximately Rs. 1,68,000) are available for Rs. 10,000 to Rs. 30,000 here. Recently, the hospital used an indigenously created bovine jugular conduit to connect the ventricle and the arteries of a 27-day-old Palestinian boy, Khalid. "These are the same techniques being used in Europe," he says. "The only other manufacturer of this conduit is a German company. We provide world-class treatment at a much lesser cost."
However, Dr. Cherian says, most of the patients are from Asia as India does not have the necessary infrastructure to cater to European and U.S. requirements. "Our roads are dirty, water is bad, even internet connectivity which people from the West consider a must is not up to their standards, despite all our claims of IT proficiency."
India has the cost advantage, the technology and clinical expertise and manpower to be an international health destination, but Government support is lacking. He advocates a holistic approach to healthcare, with entire complexes or resorts that provide the medical tourists all the facilities. The St. Gregorios Cardiovascular Centre in Parumala in Alleppey district, Kerala, set up by his institution could become such a holistic centre with the right kind of support. He describes it as a rural area with all the facilities of an urban hospital and just one hour from Kochi. "It's a 30-bed hospital, in one year, we have performed more than 500 angioplasties and 400 open-heart surgeries. It's set in the middle of a village by paddy fields and a river... it's the kind of place that is ideal for surgery, recovery and relaxation," he says.
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