INDIA - A Leading Destination of Incredible Healthcare Services by AJEESH THOMAS THAYYIL
Introduction :
Atithi Devo Bhava (अतिथि देवो भव:) is the core ethos
of Indian hospitality, the guiding thought for hosts to go out of the way in
treating guests with the same reverence as God. This philosophy guides the
Indian tourism and hospitality sector to welcome tourists from all over the
world and extend them an unforgettable experience. Coupled with the vastness of
Indian land and water bodies, the geographic and cultural diversities, and rich
historical and natural heritage, India is one of the most remarkable tourist
destinations in the world.India also happens to have an extremely rich history
of medicine going back to the Vedic times. Ayurveda, one of the oldest systems
of medicine can be traced back to 8000 BCE. The Golden Age of Indian medicine
can be traced back to 800 BCE and went on till 1000 CE, which witnessed the
writing of Charak Samhita and Sushruta Samhita. Today, many modern methods of
treatment and surgeries, such as rhinoplasty, find their roots in these
literatures.
Current State of Indian Medical
Tourism
A thriving sector globally, medical
tourism is estimated to have a market size of USD 44.8 billion in 2019, with
some 1.40 crore people traveling to different countries for better medical
treatment, essentially forming the medical tourism sector. The sector is
expected to grow at a CAGR of 21.1% from 2020 to 2027.
India is ranked 10th out of the top
46 countries in the world in the Medical Tourism Index 2020-21 by Medical
Tourism Association. While MVT for India was projected to be USD 9 billion by
2020, despite the debilitating impact of the COVID-19 pandemic on the tourism
and hospitality industry, the medical tourism sector is estimated to have been
worth USD 5–6 billion. MVT in India is expected to grow to USD 13 billion by
2022.
For a country to establish its
credibility as a medical tourism destination, it needs a world-class healthcare
ecosystem and proven prowess to conduct superlative medical procedures. The
following are some of the factors that make Indian healthcare services a
medical tourist magnet.
Methods
30
semi-structured interviews were carried out with stakeholders, from different
part of the world especially from India, to assess their views on the potential
offered by a bi-lateral relationship on medical tourism between countries.
Issues discussed include data availability, origin of medical tourists, quality
and continuity of care, regulation and litigation, barriers to medical tourism,
policy changes needed, and prospects for such a bi-lateral relationship.
Results
The majority
of stakeholders were concerned about the quality of health services patients
would receive abroad, regulation and litigation procedures, lack of continuity
of care, and the effect of such trade on the healthcare available to the local
population in India. However, when considering trade from a bi-lateral point of
view, there was disagreement on how these issues would apply. There was further
disagreement on the importance of the Diaspora and the validity of the 'rule' that
patients should not fly many hours to
obtain care. Although the opinion on the prospects for an India- to Global
bi-lateral relationship was varied, there was no consensus on what policy
changes would be needed for such a relationship to take place.
Conclusions
Whilst the
literature review previously carried out suggested that a bi-lateral
relationship would be best-placed to address the concerns regarding medical
tourism, there was scepticism from the analysis provided in this paper based on
the over-riding feeling that the political 'cost' involved was likely to be the
major impediment. This makes the need for better evidence even more acute, as
much of the current policy process could well be based on entrenched
ideological positions, rather than secure evidence of impact.
Background
In an
increasingly globalized world, countries are assessing their position on trade
in health services [1]. Debates on the subject often center on the World Trade Organization’s
General Agreement on Trade in Services [2]. This is removed from the reality,
however, where most trade takes place regionally or bi-laterally [3]. In
addition, given that there is no systematic collection of data on the quantity
of trade in health services that takes place, or the impact it has on the
health system [1], discussions on whether to liberalize this type of trade tend
to be more influenced by ideology than evidence [4]. Different types of
evidence are needed on this debate. These include basic data on trade flows
across countries, evidence of the impact of this type of trade on economies and
health systems, and a greater understanding of how such trade is perceived, in
terms of those involved in it, as barriers or facilitators, and the relative
benefits and risks it presents. It is therefore important when seeking to
understand and advise a country's position on trade to understand the various
perspectives of those involved [5]. To our knowledge, such an analysis of
stakeholder perspectives has not been undertaken in the area of trade and
health, which this paper seeks to address.
The context
for the study is medical tourism, as this is one of the highest profile modes of
trade in health services (along with health worker migration) [1]. Medical
tourism can be defined as the movement of patients across an international
border for the purposes of obtaining healthcare. This is usually motivated by
long waiting times, high costs of medical care or unavailability of care in the
patients' home country [6, 7]. This definition includes both patients paying
out of pocket and the potential scenarios where governments or insurance
companies pre-arrange foreign healthcare treatment for patients. Although
currently the vast majority of medical tourism occurs from patients arranging
and paying for the medical services abroad themselves, arguably the biggest
potential for this market lies within governments or insurance companies pre-arranging
foreign care for patients. It is therefore the potential for the development of
this latter form of medical tourism that this paper concentrates upon.
Currently most medical tourism takes place by individuals privately arranging
healthcare in a foreign country. Often, medical tourism facilitators play a
role in this by providing information on countries, hospitals and services, and
sometimes even arranging the care for the patients. This, however, occurs under
general regional or global agreements, which are by definition multi-lateral.
There are no
agreed figures for the number of people who go abroad for healthcare, and the
data available in the literature are wide-ranging (from thousands to millions)
[8]. There have been several reports from consultancy firms which are often
quoted to portray medical tourism as a market with great potential, but it is
often unclear how their data were generated [9–11]. Medical tourism raises
issues of quality of care [12], litigation [13, 14], continuity of care [15],
equity [16] and the creation of an internal brain drain, where medical
professionals leave the public health service to work for the private hospitals
that cater for (more profitable) foreign patients, further exacerbating staff
shortages [17]. Countries need to take these issues into account when deciding
on whether (and to what extent) to liberalize trade in health services.
However, a missing piece in the discussion thus far has been a focus upon what
type of trade relationship they may wish to engage in.
The literature
concerning medical tourism is expanding, and there have been several recent
attempts to synthesize what is already known about this practice [4, 8, 18–20].
Although these reviews take different perspectives on medical tourism, they all
agree on the potential benefits and dangers it can bring to importing and
exporting countries. Importing countries (those where the medical tourists come
from, as these countries are importing healthcare services) can benefit from
lower costs and reduced waiting lists; however, there are concerns regarding
quality of services and litigation procedures. On the other hand, exporting
countries (those that provide the health services to foreign patients) can
bring in foreign exchange and may prevent health professionals leaving their
country to work in overseas institutions, but risk creating a two-tiered
system, with foreign patients receiving better care than domestic patients. In
addition, reviews highlight the dearth of primary data available on medical tourism,
both at the national and international level, and call for more empirical
research to be carried out to ascertain the numbers of medical tourists and the
procedures they undergo, as well as the validity of the claims made for and
against this practice. Finally, the literature highlights the need for more and
better regulatory frameworks for medical tourism, such as the creation of
specific national medical guidelines to guide the provision of services to
foreign patients [21], the adoption of equitable buying guidelines to address
the impacts of medical tourism on equity [19], and the development of a common
international regulatory platform and reporting system, that goes beyond the
current regulatory bodies, such as the Joint Commission International [4].
Nonetheless, these alternative frameworks do not address the principle
trade-agreement between nation states, and in this respect this paper adds to
the literature by explicitly seeking to gain information relating to the
potential for a bi-lateral relationship to overcome some of the core concerns
raised thus far in the context of multi-lateral trade agreements.
The most of
the issues that arose could be better addressed from a bi-lateral relationship,
where a contract can be drawn out between the two countries outlining, for
instance, which hospitals would provide the care, what procedures would be
followed should something go wrong, what care the patients would receive before
and after going abroad, and how this relationship could improve, rather than
damage, the healthcare available to the local population. Nonetheless, there
are still questions concerning the perception of such a bi-lateral system, and
its ability to address concerns associated with medical tourism.
In an effort
to contribute further to this literature-based evidence, we took subsequently
carried out semi-structured interviews with key stakeholders in both India and
many countries in Middle East, Asia, USA, UK and Europe. The aim was to elicit
their views on the prospects and impediments for a bi-lateral trade relationship
in medical tourism perse, and specifically one between the Middle East and India as the principle case-study context
for discussion (where the Middle East was seen as an importer and India as an
exporter of medical services). This paper summarises the results from these
interviews. Following this introduction, the methodology used to undertake and
analyse the interviews is provided, followed by the results. The discussion of
these results is set within the context of the results from the previous
literature review, with the paper concluding with lessons for further research
and policy in this area.
Methods
A total of 30
semi-structured interviews were carried out, 20 in India and 10 in the Middle
East. These two countries were chosen because: (i) the Middle East area has
some experience with cross-border mobility of patients within the European
Union; (ii) India has already made some inroads as an exporter of health
services, for instance in the provision of telemedicine services, and is one of
the biggest players in medical tourism; and (iii) the two countries have
historical ties, a common language, commonalities in the educational system,
and there is a large Indian Diaspora population living in Middle East, which
would facilitate this type of trade. The balance in the number of interviews
between the two countries reflects the wider range of stakeholders in India, as
a destination for medical tourism, given the variety of the different providers
of health services, and the different levels of government and private sector
that would be involved in such a decision. The initial participants were
selected to represent the key stakeholders likely to be involved in medical
tourism as identified through the systematic review mentioned earlier; these
were healthcare providers, members of the Department of Health and medical
tourists. These stakeholders were accessed through a variety of methods.
Healthcare providers and Department of Health officials were selected according
to their role. Medical tourists were accessed through personal contacts of the
authors. During the interviews, a snowball sampling technique was used to
identify others that may have interest and be relevant to the study. The aim of
using this type of sampling was to maximize the range of opinions and
perspectives and to get as complete a picture on the subject as possible.
Recruitment was undertaken until saturation was felt to have been reached (that
no new substantive issues were being raised). The stakeholders that took part
are listed in table 1. In addition, workshops were held in both India and the
UK before and after the interviews took place with officials from the
Department of Health, researchers, think tanks, medical professionals and hospital
managers. The aim of the workshops was twofold: (i) before the interviews took
place, to map out the issues and different perspectives on medical tourism, in
order to guide the development of the semi-structured interview schedule; and
(ii) after the interviews, to corroborate the findings and obtain any further
insights.
Data
availability
The review of
the literature carried out previously by the authors had shown that there was
very little data, and of poor quality, available on medical tourism flows. This
is of concern, since in order to determine the scale and impact of medical
tourism, data is needed by policy-makers on, for instance, the numbers of
medical tourists, the revenues these bring, the outcomes of treatment and the
impacts medical tourism has on the home and destination health system. Some of
the Indian healthcare providers interviewed estimated that foreign patients
made up 5-7% of all patients they treated, with foreign patients representing a
slightly higher share of revenue source (although this figure includes foreign
patients that were not medical tourists). Many respondents quoted figures from
reports carried out by the Confederation of Indian Industries, We are
suggesting the promising prospects for medical tourism, rather than actual
current figures, whilst others, such as medical tourism facilitators, were
highly critical of these reports:
Medical
tourism is a much overhyped market. People have a vested interest saying it is
the next big thing, but the numbers are exaggerated ... However, because of
these high figures, people see it as a growth market, which results in too many
organizations in the market (hospitals, countries, agents) but not enough
patients to go round. (Respondent #6, UK medical tourism facilitator)
In general, it
was clear that the stakeholders interviewed had very little information on the
current status of medical tourism in general, and that related to India and the
UK specifically, generating concern for the development of policy concerning
this area.
Origin of
medical tourists
Most
respondents commented on the target population for the private hospitals in
India that attract medical tourists. When asked about which countries
international patients came from, most participants from India named
neighbouring and low-income countries, with the UK rating low on their priority
list. A typical response was that:
The bulk of
foreign patients come from Afghanistan, Bangladesh, Nigeria, Iraq, and
Ethiopia. The SAARC [South Asian Association for Regional Coordination] countries
account for 50% of all foreign patients, another 20-25% are from Afghanistan,
3.5% or so from the Middle East, 3% from the US ... The UK is not a large
market (Respondent #18, Indian healthcare provider)
There was also
widespread agreement, both from the respondents in the UK and in India, that
the Diaspora community would be willing to travel back "home" for
treatment. However, opinion was divided on the significance of this population.
Most of the UK and some of the Indian stakeholders believed that the number of
these potential travellers would be small in absolute terms:
There are
small numbers of citizens of an Indian origin that would benefit from this type
of arrangement, for cultural or religious reasons, but the numbers are small
(Respondent #1, UK Department of Health)
Whereas, the
majority of the Indian participants believed them to be a key target group for
medical tourism:
The main
audience could be the NRI [Non-Resident Indian] population in these developed
countries (Respondent #12, Indian industry association);
Nonetheless,
there was widespread agreement between stakeholders that hospitals in India
should concentrate on the large domestic market, before targeting foreign
patients; this was the view of government officials in both countries, members
of academic and industry associations, although, perhaps predictably, only a
small proportion of the Indian healthcare providers.
Indian private
hospitals argue they have a lot of extra capacity. However, it is hard to
believe they are covering the whole of the Indian population (Respondent #5, UK
industry association)
The negative
part of this is that to chase that foreign segment of patients, we may end up
neglecting others needing healthcare in our own country (Respondent #11, Indian
NGO)
The medical
tourists interviewed did not comment on this issue.
Quality,
perception, regulation and litigation
The majority
of the UK stakeholders interviewed showed concerns regarding the quality of
healthcare in India, and a potential lack of regulation.
In the UK we
have the Care Quality Commission, guidelines, etc., but how do you ensure that
the standards are the same or better? (Respondent #4, UK healthcare provider)
However, this
was contradicted by most of their Indian counterparts, who believed healthcare
providers in India have made great progress in obtaining national and
international accreditation, and that the standard of care was very high. They
were, though, very aware of the poor perception that the UK had of Indian
healthcare.
The main
barrier is perception ... but the procedures and staff are of top quality ...
Quality is not a problem for Indian corporate hospitals as 70-80% of their
doctors are often trained in the UK and the standards are equivalent to those
in the US or the UK (Respondent #17, Indian healthcare provider)
Now NABH
[National Accreditation Board for Hospitals & Healthcare providers] is
ISQua [International Society for Quality in healthcare] accredited. By this
certification, the basic level of hospital quality is now ensured in India.
Nevertheless,
this was not the opinion of all Indian stakeholders: whilst most healthcare
providers agreed that standards were high and regulation was necessary, some
members of academic and industry associations believed the accreditation
industry was not as reliable as some believe it to be, and many establishments
were wasting their money getting different types of accreditation.
There is
concern that now with the NABH and the insistence on it being mandatory,
quality may come down over time ... There is also corruption among the auditors
and the process of accreditation can be questioned.
When
discussing quality concerns, most participants linked these to the issue of
litigation, which was a concern across the board for Indian and abroad
stakeholders.
Under a
bilateral agreement, care in India would be commissioned by any country, and
therefore the these countries are automatically responsible for any litigation
payments, which would outweigh the savings made.
There are
concerns about medical malpractice. The company has decided to stay away from
issues of liability. There are indemnity clauses built in. Interestingly, the
medical tourists that took part in the interviews did not think they had the
right to any sort of compensation, only one had ensured that the hospital would
take full responsibility and carry out any further procedures for free should
anything have gone wrong. One medical tourist had experienced bad quality and
potential medical malpractice, but no action was taken.
Three hour
'rule'
One of the
most controversial issues was the three-hour 'rule'. This 'rule' was supposedly
devised by the UK Department of Health when considering sending patients for
care to other EU countries, as part of EU-wide legislation, stating that
patients were not allowed to be treated in countries that were more than
three-hours flying time away. The participants from India thought that this was
a major formal barrier for the NHS when considering sending patients to India.
The main
problem is the three hour restriction by the NHS. This has to be taken up in a
bilateral dialogue with the UK on a regular basis and the time has to be
increased to eight hours to cover India (Respondent #21, Indian Ministry of
Health)
However, the
opinion in the UK was divided. Although respondents from industry considered it
an important barrier, it was interesting that participants from both the NHS
and the Department of Health considered it only "informal guidance":
This is
neither a legal rule nor formal guidance. How far someone can travel depends on
the clinical needs of the individual. The three hour rule is not a formal
binding, and it is not used ... it is up to consultants and PCTs [Primary Care
Trusts] to decide how long someone can travel ... It wouldn't make sense, as
there are areas within the EU that are further than 3 hours! (Respondent #1, UK
Department of Health)
The patients
interviewed strongly disagreed with the 'rule':
It's a
ridiculous rule. If they are willing to consider sending patients to the EU on
a case-by-case basis, then they should use that same basis to let them go
further. This would not be the case for patients that would need heart surgery,
but for things like knee, joints, fingers, eyes, etc. (Respondent #8, medical
tourist)
Clearly the
status of such a 'rule', illustrative of other perceived barriers in other
contexts, is of major significance to establish in any discussions about more
formal trade agreements in this area.
Continuity of
care
The problem of
continuity of care was highlighted by all groups of participants, both in the
UK and in India. In fact, for the UK respondents, it appeared to be a more
important issue than the 'three-hour rule'.
If they
[medical tourists] need continuity of care, especially if problems occur, who
is going to be there to fix them? There would be an unwillingness here [UK]
(Respondent #4, UK healthcare provider)
Patients also
showed concerns about continuity of care, although they did not express any
problems in getting care once they returned.
They [domestic
healthcare providers] should at least arrange the aftercare and pre-treatment
for those that choose to go privately, as they would be saving money by not
having to operate on them (Respondent #9, medical tourist)
Prospects and
policy changes needed
In general,
respondents believed the prospects for a bi-lateral relationship in this type
of trade in health services between India and the UK to be low given the
present circumstances.
The UK
government ... does not see what value there would be from setting such an
arrangement (Respondent #1, UK Department of Health)
We are not a
good option for the UK (Respondent #12, India industry association)
When asked
about what policy changes would be needed to enable this relationship and what
(if any) role the governments on each country should play, there was widespread
disagreement amongst the participants. Although most of the UK participants
showed some concern regarding the level at which changes should take place,
they all believed whatever changes were required simply would not happen.
It is never
going to happen ... It could not happen politically. It may make logical sense,
but it would never happen in the real world (Respondent #6, UK medical tourism
facilitator)
A very
sophisticated bilateral agreement would need to be produced. But the NHS is
facing bigger problems at the moment, and no government would devote resources
to achieving that (Respondent #7, UK think tank)
The Indian
participants disagreed on whether the Indian government should be actively
involved in facilitating medical tourism. The majority of the respondents,
including those from Indian healthcare establishments, believed that the
government should be involved, whereas the respondents from the Ministry of
Health and academic and industry associations did not.
The government
of India should focus on medical value travel as a source of foreign exchange.
It can also help improve standards, skills, enable international accreditation
and in the process help domestic patients (Respondent #18, Indian healthcare
provider)
The official
position can never be to focus on medical tourism as this would be perceived as
coming at the cost of public health (Respondent #21, Indian Ministry of Health)
Overall,
although there was some indication that movement toward a bi-lateral agreement
on medical tourism may make some sense on both sides, the political 'cost'
involved was likely to be the major impediment to any movement in practice and
in the foreseeable future.
Discussion
Of the key
themes identified, there was agreement between the stakeholders on the
importance of regional travel and proximity, quality, regulation, litigation,
continuity of care and the low prospects for a bilateral relationship between
India and the UK on medical tourism. However, there were disagreements on the
importance of the Diaspora in medical tourism, whether countries like India
should concentrate on the local population before offering services to foreign
patients or if they should focus on this industry to raise foreign exchange,
the status of the three hour 'rule', and what policy changes would be needed
for such a relationship to prosper (including the role of government).
These results
are subject to two important caveats. First, two different interviewers were
involved (one in the UK and one in India), and although the same interview
instrument was used there may have been differences in the way questions were
asked or answers recorded. Second, the stakeholders approached in India were
more willing to participate in the interviews than those approached in the UK.
This means that the opinion of those who were not willing to participate from
the UK was not represented.
This research
supports some of the concerns found in the literature, including quality of
care [14], litigation [13, 25], continuity of care [15, 26] and the potentially
harmful impact medical tourism may have on the local population [19, 21, 27].
However, as highlighted above, not all stakeholders were in support of these
arguments. In addition, this research has shed some light on other issues, such
as the uncertainty surrounding three hour 'rule', the importance of the
Diaspora and has provided some indication on the amount of foreign patients
that Indian private hospitals provide medical treatment to. Although the UK and
India were selected as a case study in this research, this is not an exclusive
example where this type of trade could take place. The UK has cultural links
with many other countries where English is widely spoken that offer medical
tourism services, and India attracts medical tourists from across the world.
Nevertheless,
when policy makers have to make decisions on whether to engage in this type of
trade, this takes place largely in a data vacuum, given that there is no data
on the amount of medical tourism that goes on, and what impacts it has on the
exporting and importing health system. As this research shows, opinion amongst
stakeholders in this field is often divided. These issues cannot be resolved
until more and better quality data becomes available.
More research
is needed to determine the flows of medical tourism, including the total
numbers, what countries they come from and where they get treated.
Additionally, it is essential that there is more evidence on the impact medical
tourism is having, both on importing and exporting countries, as at present, it
is impossible to know whether the concerns outlined in the literature and in
these interviews are likely to be realised. Finally, it is of particular
importance to examine the effect different types of trade relationships might
have. In this respect, whilst the literature review previously carried out by
authors suggested that a bi-lateral relationship would be best-placed to address
the concerns raised regarding medical tourism, there was scepticism from the
analysis provided in this paper based on the over-riding feeling that the
political 'cost' involved was likely to be the major impediment. This makes the
need for better evidence even more acute, as much of the current policy process
could well be based on entrenched ideological positions, rather than secure
evidence of impact.
This research
can also provide some policy recommendations. The literature suggests that
medical tourism can cut costs, improve waiting lists (from the perspective of
importing countries) and generate revenue and improve the national healthcare
(from the perspective of exporting countries). Given these, policymakers should
consider medical tourism as an option to improve their health services. This is
particularly important in the current climate where countries are facing budget
cuts spurned on by the financial crisis. When evaluating the different options
available, policymakers should consider engaging in a bi-lateral relationship,
as it has the most potential to ensure the interests of the patients on both
countries are prioritised. This could also be addressed through the ongoing
EU-India trade negotiations, which also cover services.
In conclusion,
there are a wide variety of barriers affecting medical tourism, including
restrictions on travel by governments and concerns about quality, regulations
and litigation. In order to increase trade, these barriers need to be
addressed. The results from the literature review reported elsewhere [Smith R,
Martínez Álvarez M, Chanda R: Medical Tourism: a review of the literature and
analysis of a role for bi-lateral trade, Submitted] suggests that a bi-lateral
relationship is best-placed to tackle these barriers. However, results from the
analysis reported here suggest that it is the political sensibility that is the
major barrier to be overcome. In this respect, it is worth remembering that
policy decisions affecting this type of trade in health services are largely
taking place in a data vacuum. It is therefore imperative for more studies and
surveys to be carried out and for more empirical data to be collected, in
particular data on the size of the medical tourism market, pricing of services,
regional breakdown of markets, and the impact of different forms of trade
agreement.
