9

Chapter 2

Concept of Medical Tourism

2.1 Medical Tourism Concept

2.1.1 Definition of Medical Tourism

2.1.2 Medical Tourism Growth

2.1.3 Medical Tourism Global Scenario

2.2 Medical Tourism Insurance

2.2.1 Medical Tourism Insurance Market

2.2.2 Ethical Legal aspects of Medical Tourism

2.2.3 International Patient Satisfaction and Experience

2.3 Trends in Medical Tourism

2.3.1 Domestic Medical Tourism

2.3.2 Benefits of Medical Tourism

2.3.3 Healthcare Cluster

2.3.4 Healthcare & Medical Tourism Education

2.4 Other Forms of Medical Tourism

2.4.1 Wellness Tourism

2.4.2 Alternative Medicine

2.5 Healthcare scenario and Medical Tourism in India

2.5.1 Healthcare Infrastructure in India

2.5.2 Medical City Projects in India

2.5.3 Medical Tourism in India

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Chapter 2 Concept of Medical Tourism

2.1 Medical Tourism Concept

Medical Tourism is new area for research, the concept of medical tourism has coined some years

back, so that research on medical tourism has been started just few years ago. There is no doubt

that medical tourism is one of the significant areas of research and publication in tourism. From

the academic literature on medical tourism apparent that research on medical tourism to date has

been largely conceptual in nature, and major gaps exist in the evidence base supporting research.

Medical Tourism Research to date often focuses on exclusively on those who travel abroad to

developing countries for medical services now it’s time to focus on organisation and management

of medical tourism.

In this chapter introduce with the concept of medical tourism, definition of medical tourism, global

scenario of medical tourism and new trends in medical tourism. The Chapter also highlights other

forms of medical tourism and role of insurance company as well patient safety in Medical Tourism

.

2.1.1 Definition of Medical Tourism

There is no proper definition of medical tourism. Many researchers, authors and experts have tried

to define and re-define Medical Tourism, and some have even gone to extremes to create new

words to define the industry of patients traveling from one country to another for medical care.

Medical Tourism is actually a side effect or after effect to the Globalization of Healthcare.

Medical Tourism is a direct result of Globalization of Healthcare; the industry is coming up in

vigorous speed. This emerging industry is set to boom because of several factors which are not

defined or observed clearly. In order to define its right objectives, we need a proper definition for

“Medical Tourism.1”

1 Medical Tourism Association , Defining Medical Tourism ~ Another Approach by Dr Prem

11

The word “Medical” means treatment of illness, disorder or injuries. In general, “Tourism” means

traveling for pleasure. According to World Tourism Organization (WTO), the word “Tourism”

compromises of “the activities of persons travelling to and staying in place outside their usual

environment for leisure, business and other purposes.”2

Understanding of word medical and tourism individually is not sufficient to define Medical

Tourism. Medical Tourism is a combination of various and definite activities and clear

understanding of such activities is essential.

Considering the above sets of definitions, the following can be observed: When a person travels

across the border and outside their usual environment, to seek medical service, the travel portion

of the trip travel is called “medical travel”, and upon arrival, such person is called “medical tourist”,

and such activities which includes utilization of medical services by the medical tourist, be it direct

or indirect - hospitality, cultural exposure or site-seeing, is called “Medical Tourism”.

Hence, Medical Tourism could be defined as set of activities in which a person travels often long

distance or across the border, to avail medical services with direct or indirect engagement in

leisure, business or other purposes.

But generally, the health professionals do not prefer to mix the word “medical” with “tourism.”

They have an idea that the word tourism reduces the value of decision which is primarily made for

medical services. They also argue that not every patient get involved in tourist activities. An

interesting argument would be if patient travels abroad, he/she would be certainly exposed to the

culture, environment, food, heritage, leisure or other various aspects of destination’s activities that

could be tourism.

One way to define and identify patients who are treated outside their home country is to study

their motivation to seeking health care abroad. Using this criterion, we can distinguish two

different categories of patients. The first group covers patients who travel abroad for the sole

purpose of receiving healthcare services. Such patients might travel long distance to receive

2 Vincent C. S. Heung, Deniz Kucukusta and Haiyan Song, “A Conceptual Model of Medical Tourism: Implications for Future Research,” Journal of Travel & Tourism Marketing, 2010, 236–251 <doi:10.1080/10548401003744677>.

12

medical treatment or might just be residents of border areas. Their reasons for seeking healthcare

abroad are numerous, including higher quality or lower cost for treatment. These patients might

also decide to combine their medical treatment with tourism. The second group includes all those

person who are already abroad, who fall sick and need health care during their stay. This category

includes temporary or migrant worker, retirees abroad and tourist. (Matthias 2011)

According to annual report 2010-11 published by Ministry of Tourism, Government of India

Medical Tourism is also called Medical Travel, Health Tourism, or Global Healthcare, these term

used to describe the rapidly growing practice of travelling across international borders to obtain

healthcare. Services typically sought by travelers include elective procedures as well as complex

specialized surgeries such as joint replacement ( Knee / Hip ), cardiac surgery, dental surgery and

cosmetic surgeries however, virtually every type of health car, including alternative treatment

available.(Sawant2011)

Medical tourism is a broadly defined industry which is prejudiced by a multitude of factors. On a

microeconomic scale, this niche industry is affected by a multitude of supply and demand factors

including consumer demand, cost factors, and local, regional, or national factors including

economic policy, political environment, regulations, infrastructure, capital investment, and

destination marketing3. As relatively little research exists on the subject of medical tourism, and

recent changes in the global economy have significantly impacted the market, there is not

sufficient information for the hospitality or tourism professional to be informed regarding the

decisions with regards of healthcare tourism. Furthermore, the existing research is often narrow

in focus, and often views the market from a public policy or medical discipline, and so may not

provide the hospitality and tourism industries with a full picture of the factors involved in catering

to the market.

Medical tourism is a term used frequently in media and reports however, different commentators

tend to include different ingredients within the scope of its definition. It is usually used to refer to

persons who travel outside their countries to obtain medical care, but often, foreign tourists who

require some medical care during their stay in the destination country, even though medical care

3 Krista Wendt, “Medical Tourism : Trends and Opportunities”, 2012.

13

was not the primary purpose of their travel, are also included within its ambit. Sometimes

expatriates and their families living in the country and seeking medical care are also included,

whereas others also include tourists availing traditional healing methods and health promoting

services like spa and massage. Such variance in the use of the term has created a significant

limitation in the comparison of statistics and trends. Another term often used is ‘medical traveler’,

is defined as a person who travels beyond her country with the primary intent of obtaining medical

care.

Milica Bookman and Karla Bookman (2007) define medical tourism as travel with the aim of

improving one’s health, and also an economic activity that entails trade in services and represents

the splicing of at least two sectors: medicine and tourism4. Michael Moody (2007) indicates that

the medical tourism trend began when residents of one country would go to another country to

have cosmetic or dental procedures completed while on vacation or to recover from such

procedures in a vacation like destination.

Medical Tourism is defined and distinguished from health tourism as the combination of travel to

a vacation destination for a potential leisure experience and a specific medical intervention.

Medical tourism, alternatively called health tourism and wellness tourism, is a term that has risen

from the rapid growth of an industry where people from all around the world are traveling to other

countries to obtain medical, dental, and surgical care while at the same time touring, vacationing,

and fully experiencing the attractions of the countries that they are visiting. It is a silent revolution

that has been sweeping the healthcare landscape of India for almost a decade.

From the above definitions there is no uniform or universally accepted definition of tourism. The

United Nations World Tourism Organization and Health and Ministry of External Affairs have not

yet defined medical tourism. However UNWTO defines visitors as “any person travelling to a place

other than that of his/her usual environment for less than 12 months and whose main purpose of

the trip is other than the exercise of an activity remunerated from within the place visited.” Visitors

are further sub-dived into two categories: tourist, who must stay one or more night in the place

visited, and same day visitors, comprising visitors who visit a place and return the same day

4 Milica Z. Bookman; Karla R Bookman, Medical Tourism in Dveloping Countires.

14

(without overnight stay). This definition recognizes the following categories as characterizing the

main purpose of travel for tourist: leisure, recreation and holidays, visiting friends and relatives,

business and professional (including for study), health treatment, religion, pilgrimage and sports.

Definition mentions about the health treatment as purpose of travel. As observed all these

definitions and literature reviewed, In simple word Medical Tourism is the process of travelling

abroad to receive superior medical, dental cosmetic care by highly skilled surgeons at some of the

most modern and state of the art medical facilities in the world where the cost of treatment is

comparatively very low then their home country. If the person travel only for medical treatment it

would be medical travel and person engaged in tourism activities visiting nearby tourist destination

that process is called medical tourism.

2.1.2 Medical Tourism Growth

Medical Tourism is one of the fastest growing industries within healthcare. Currently millions of

patients are traveling internationally and spending billions of dollars per year on healthcare. It is

estimated that the worldwide medical tourism industry is valued at over $40 billion dollars and is

growing.5

The growth of the industry is occurring because of a rising middle class in many countries and the

internet’s role in making patients much more educated about their health conditions. The

important role is also of early screening and preventative medicine and a greater availability of

information about state of the art advanced curative treatments. In today’ s age when a patient

has a poor health condition, their first stop is the internet for research and the internet can then

lead them to answers, not just in their home country, but other countries as well.

These internet savvy patients are searching for where they can get the best medical care at an

affordable price and many of them have started to get onto airplanes and travel for this medical

care. Patients are traveling around the world for orthopedic surgeries such as knee and hip

replacements, heart surgeries, transplants, cancer treatments, and alternative treatments,

amongst other cosmetic and dental surgeries. Multiple factors help to explain the recent explosive

5 Medical Tourism Association, Medical Tourism Association Annual Member Report 2008-2009, 2010.

15

growth in the industry and suggests a continuation of growth in the future worldwide, including

demographics, technological change, globalization, geopolitical trends, and economic trends6.

Top emerging destinations for medical tourism include India, Costa Rica, Mexico, Guatemala,

Turkey, Argentina, Brazil, Korea, Philippines, Singapore and Thailand. More than 40 countries are

now competing for medical tourism patients and more countries and hospitals are entering this

new competitive marketplace.

There is a real opportunity emerging for those countries which are catering to developed countries,

like USA, Canada, United Kingdom and other European countries, where the cost of healthcare can

be 90% higher compared to other countries7. The demand of Medical Tourism services primarily

comes from three categories of consumers (patients)

1. Non Residential

2. Patients from countries with under developed facilities

3. Patients from developed countries

Non Residential category patient’s demands are low cost healthcare with a trip back home. For

second category patients who are from under developed countries, demands are quality

healthcare at affordable prices; in such countries like Tanzania, Uganda and another African

countries healthcare facilities are not appropriate for major surgical procedures. Third category

where patient from developed countries demand for low cost healthcare and expect service like

their home countries like US, UK and Canada. Some developed countries have good healthcare

infrastructure and healthcare services but religious purpose has banned some surgical procedure

like organ transplant and IVF. There is a big market at UAE to cater such kind of patients from all

over the world. Healthcare providers are playing an important role in the Global healthcare market

place.

6 Carolina Peguero and Laura Roche-, “Medical Tourism : a Survey”, 2010. 7 Dr. Prem Jagyasi, “Defining Medical Tourism”, 2008.

16

Fig 2.1 Inbound Tourism by Purpose

Source: World Tourism Organization (UNWTO)

As per the WTO report ‘Tourism Highlights 2013’ mentioned that in year 2012, travel for holidays,

recreation and types of leisure accounted for just over half of all international tourist arrivals (52%

or 536 million arrivals). Some 14% of international tourists reported travelling for business and

professional purposes and another 27% travelled for other purposes, such as visiting friends and

relatives (VFR), religious reasons and pilgrimages, health treatment, etc. The purpose of visit for

the remaining 7% of arrivals was not specified8.

2.1.3 Medical Tourism Global Scenario

A combination of multiple factors has contributed to the recent increase in popularity of medical

tourism. High cost of healthcare in the industrialized nations and the dramatic reduction in cost of

international travel together has created a market for medical tourism. At the same time a

destination is needed for these medical tourists. In the recent years, the medical technology and

standards of healthcare in many developing countries has seen a revolution. Today, countries like

India, the East Indies, South America and South East Asia offer treatment facilities at par with

international standards at just a fraction of cost. Also, these countries offer numerous options for

touring, sight- seeing, shopping, and exploring. With the current growth rate of medical tourism it

8 UNWTO, Tourism Highlights 2013, 2013.

17

is expected that destinations for medical tourists will also increase rapidly as healthcare facilities

improve around the world.

There are around 30 countries recognized as medical tourism tourist destination across the globe.

All these medical tourism destinations are trying to attract international patients with their cost

effectiveness, specialized treatment, alternative treatment and advance surgical procedure. In

India, most preferred treatment is joint replacement, wellness in Thailand, Spa treatment in

Costrica and Turkey and cosmetic Treatment in Venezuela.

Through the literature reviews and reports identified top medical tourism destinations.

Brazil: This destination offers you a great pool of talented doctors in almost any field of medical

specialty. Also, Brazil is undoubtedly well-known for its largest number of cosmetic doctors

globally. It not only offers the best of healthcare services in its major cities, but also at smaller

places like Santos and Porto Alegre. Within three to six thousand dollars, you may receive various

specialized procedures, including face lifts, tummy tucks, rhinoplasty and breast augmentation.

Costa Rica: There is a good share of about 15 percent of the international medical tourists that this

country attracts. People mainly come to get dental services and cosmetic surgeries done by

certified dentists and surgeons. Most of the patients from the United States count it as their

preferred medical tourism location for cost-effective healthcare services.

Life Expectancy M 77 / F 82 and Patients: Physician Ratio N/A

Hungary: Across this whole country, you may anywhere find a good dentist providing the best of

dental care services to the patients. Hungary has the largest number of skilled dentists in the world.

Now, many patients come to this destination for receiving not only dental care services, but also

several types of implants, cosmetic oral surgeries and complete mouth restorations.

India: There are innumerable American, European and Canadian tourists who come to India every

year for getting expensive orthopedic and cardiac procedures and surgeries done. These

specialized procedures are quite costly within their own countries, but in India, patients can get

them done at a far lower cost. There are state-of-the-art medical facilities located all across the

18

country and especially in its larger metropolitan cities. Medical tourism has been increasing at a

high rate of 30 percent per year in India.

Life Expectancy M 62 / F 64 and Patients: Physician Ratio 1700: 1

Malaysia: With its specialized medical skills and facilities, as well as lower treatment costs,

Malaysia has become a preferred medical tourism destination for about a quarter million people

per year. The country has special centers for burn treatments and offer cost effective packages for

preventive care.

Life Expectancy M 71 / F 74 and Patient: Physician Ratio 1400: 1

Mexico: This is undoubtedly a preferred medical tourism destination for various U.S. citizens as the

country gets benefitted due to its convenient location. People in many of the U.S. states take about

a few hours to travel to Mexico. Thus, it is quite easier to get to and fro. Patients surely get the

benefit of minimal travel, along with effective treatments, checkups and physicals done.

Life Expectancy: M 72 / F 68 and Patient: Physician Ratio 500: 1

Singapore: It is a tiny Asian country but is a veteran when it comes to medical tourism. World

Health Organization (WHO) has ranked its healthcare system as the best in Asia and one of the top

systems in the world. That is the reason many patients visit this country for getting specialized

treatment in a variety of medical specialty areas, including cardiology and heart surgery,

orthopedics, oncology, hepatology, general surgery, ophthalmology, neurology, gastroenterology,

and stem cell therapy. This destination also offers the best of medical facilities and infrastructure.

Life Expectancy M 65 / F 69 Patient: Physician Ratio 800: 1

South Korea: This destination provides some of the most advanced scientific and technological

facilities in the world of healthcare. Patients generally visit here for getting spinal and cosmetic

surgeries done. They also get cancer screenings and treatments done at a much lower cost than

they would get done in their own countries. There are some world-class, fully digitized hospitals in

South Korea. Medical travelers can also get various types of herbal medicines from its historical

medicine markets.

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Life Expectancy M 77 / F 82 and Patient: Physician Ratio 300: 1

Thailand: This destination rules for its cosmetic surgical procedures and its amazing facilities having

excellent infrastructure. There is a good inflow of patients from China, Japan, South Korea and

Vietnam and from other western countries. Elective surgeries are very cost-effective in Thailand

and almost made up for patients’ trips.

Life Expectancy M 69 / F 75 and Patient: Physician Ratio 2700: 1

Turkey: Apart from the Unites States, It is only Turkey that has the maximum number of JCI-

accredited healthcare facilities in the world9. Healthcare costs in Turkey are quite low, and there is

no dearth of well-qualified and certified doctors in this country. Whether it is about the medical

technology or its staff and facilities, Turkish government has never compromised on its quality

standards.

Life Expectancy M 71 / F 75 and Patient: Physician Ratio 750: 1

2.2. Medical Tourism Insurance

Insurance is one of the main concerns of tourists while taking treatment away from their native

country. Initially, medical tourism was popular for elective procedures that aren’t normally covered

under standard policies. These included face-lifts, breast augmentations, and other types of plastic

surgery. But now, tourists go abroad for critical and lifesaving procedures too, such as kidney

transplants, arterial bypasses, knee replacement, etc. Quite naturally, insurance is becoming a

major concern in the medical tourism world, and it is important to understand what options are

available to international patient as well medical tourism industry (2009,Renee)

Medical tourism insurance offers competitive insurance for medical patients traveling abroad and

covers them against unforeseen costs. Medical tourism insurance covers varied aspects of the

medical trip such as trip cancellation protection, travel accommodation reimburses, unforeseen

9 Dr Prem ’Guide book on Medical Tourism’

20

medical expenses not covered by the scheduled medical treatment etc. Medical tourism insurance

in most cases also covers unexpected expenses such as lost baggage while in transit.

Concept of Medical Tourism Insurance

As Insurance defines protection against risk and unfored seen events leading to pecuniary losses

which can be measured in terms of money and can be mitigated financially Medical tourism

insurance products are an emerging part of the health tourism industry10. Companies that provide

insurance products for medical travel services will be seen by potential patients as having an

advantage over their competitors. The American Medical Association agrees that an expanding

group of medical insurance company have consented to bear at least a portion of the cost of

medical tourism. Medical Tourism which was previously the territory of the uninsured and the

underinsured is now being considered by industry like CIGNA, Aetna and Blue Cross. These

companies state that they have started considering pilot programs that will offer partial travel

medical insurance.

There are a number of international travel health insurance and trip cancellation insurance

providers. They often have a network of providers worldwide. The network may contain hospitals,

clinics, medical spas, and physicians, as well as air ambulances, house call physicians, medical

escorts, and various other providers geared uniquely to the travel and medical tourism insurance

industry. These companies offer a number of different types of policies each designed with specific

coverage.

A report published by Mckinsey & Co. assesses that if insurers started providing travel medical

insurance, then annually around 500,000 to 700,000 Americans may travel overseas for surgery

Mckinsey and Co. estimate that the money saved on treatments conducted abroad could reach

$20 billion yearly11. This could be the reason behind the growing trend of medical travel insurance.

10 Jonathan Edelheit, “Implementing Medical Tourism into Health Insurance Plans”, 2008. 11 http://www.imtj.com/news/?entryid82=428625

21

2.2.1 Medical Tourism Insurance Market

Insurance companies are implementing Medical Tourism program, while some insurance

companies and employers are partnering directly with hospitals, many are looking to partner with

Medical Tourism Facilitator. Recognition of medical tourism as a viable marketplace, and the need

for medical tourism insurance are driving the changes that will benefit all the medical tourism

players. OnlineMedicalTourism.com, as well as the rest of the medical tourism industry, is

beginning to see medical insurance evolve.

A study found that if 10% of patients scheduled for 1 of 15 "highly tradable" surgical procedures

were to travel abroad, the United States would save $1.4 billion annually since costs are

significantly lower in the developing world12 As mentioned, US insurance companies and medical

tourism companies have already taken the lead in moving forward with the growth of medical

tourism. In the majority of insurance plans incorporating medical tourism, customers selecting

these plans will obtain treatment at US health care facilities for emergency care; customers

requiring elective procedures will have to travel to international hospitals Based on literature

review and online discussion on LinkedIn it is found that there are some companies providing

medical tourism insurance and have their own norms in terms of eligibility and claim processes.

Table 2.1 Medical Tourism Insurance provider

Sr

No.

Name of Medical Tourism

Insurance Provider Profile Country

1 Angelis: International medical

travel insurance

Angelis is the specialist provider dedicated to the best travel

insurance for Cosmetic, Dental and Medical Tourism. UK

2 Med Tour International

Medical Insurance Group

The product is a combination of Travel Medical Insurance

and Medical Complications Insurance. The complications

coverage is for post-surgical issues that may arise such as

USA

12 OECD, “Global Insurance Market Trends”, 2012.

22

infections, heart problems, pulmonary embolization that

may result in hospitalization or surgery.

3 Medical Tourism Insurance,

Interhealth Technologies

International health insurance companies as well as

International Corporates and Government Agencies, to

manage the local & regional healthcare for their clients and

employees.

South

Africa

4 Seven Corners : Medical

Tourism Insurance

Travel insurance that addresses the unique needs of the

medical tourist. Specifically, how will complications after

your treatment be paid for abroad or once you return home.

USA

5

Marcus Hearn Health Traveler:

International medical travel

insurance

Company has been designed by Marcus Hearn specifically for

those persons travelling abroad in order to obtain either

medical treatment or cosmetic surgery.

UK

6

All Clear Treatment Abroad

All Clear Treatment Abroad provides specialist travel

insurance for patients travelling to have medical treatment

abroad or elective surgery abroad. The travel insurance can

include special cover for additional accommodation or travel

expenses in the event that recovery from treatment extends

past the anticipated date.

UK

7 P J Hayman: Medical tourism

insurance

The travel insurance solution for people travelling abroad for

cosmetic, dental, elective or spa treatment A specially

designed travel insurance policy for medical tourism from

travel insurance specialists P J Hayman & Company.

UK

8 Medical Travel Shield

Cover includes going abroad for Cosmetic, Medical, Dental

and Fertility Treatment. The policy covers non-refundable

treatment deposits, if a patient has to cancel or delay their

trip. The policy covers treatment in a hospital, clinic or

surgery which is recognized, registered and regulated by the

relevant local government health authority or its equivalent

body.

UK

23

9 Global Protective Solutions

(GPS)

Medical Travel Accident Insurance for Individuals and Groups

Specialty Travel Insurance designed specifically to meet the

needs of the medical travel / medical tourism industry.

Global Protective Solutions provides benefits for people

travelling for the purpose of receiving medical care outside

of their home country.

USA

10 Medical Tourism

Insurance.com

Medical Tourism Insurance uses its extensive International

experience to provide distinct and customized

comprehensive medical insurance solutions that fit the

needs of individuals, employers, hospitals, and facilitators.

With the growth of the medical tourism industry, we offer

the appropriate solutions for patients and providers.

USA

Source Researcher has collected information from Insurance company’s websites

Table 2.2 Medical Tourism Pilot Programs within Health Benefits Plans

Insurer State Foreign Medical

Site

Program Summary

Anthem Blue

Cross and Blue

Shield (WellPoint)

Wilsconsin

Apollo Hospital,

India

Will send the employee of Seigraph, Inc., a corporate

client of Anthem WellPoint, to Apollo Hospitals for certain

elective procedures; the program will start with Delhi and

Bangalore facilities and later expand to all JCI-accredited

Apollo Hospitals

. Pilot project will cover about 700 group members

All financial details, including travel and medical

arrangements, will be managed by Anthem WellPoint

United Group

Program

Florida Bummgrad,

Thailand Apollo

Hospitals, India

Actively promoting medical tourism to more than200,000

individuals covered through self-funded health plans and

fully-insured, mini-med plans

Blue Shield and

Health Net

California Mexico Coves about 20,000 patients

Focused on employers that hire a large number of

Mexican immigrants

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Blue Gross

Blue Shield

South

Carolina

Bummgrad,

Thailand

Will cover patient’s procedures organized through

Companion Global if their plans cover travel

Will also cover follow-up visits with physicians at Doctors

care

Source: Deloitte, Medical Tourism Updates and Implications

Apollo Hospitals has signed an agreement with a US based insurance company Anthem Blue Cross

and Blue Shield a subsidiary of Anthem Well point13. WellPoint is one of the largest healthcare

insurers in the US. As per the agreement Anthem WellPoint will initially send the employees of

Serigraph Inc., a corporate client of Anthem WellPoint, to Apollo Hospitals for certain elective

procedures at Delhi and Bangalore Apollo Hospitals will be sending the patients to all JCI accredited

Apollo Hospitals in the later phase. All the patients will be routed through their global TPA, Mondial

Assistance, and USA which is already empanelled with Apollo Hospitals. Health base would handle

on-the-ground logistics support, which again has a tie up with Apollo Hospitals.

A high level team from Anthem WellPoint and Mondial visited the Apollo hospitals. Their standard

of evaluation was based on the quality healthcare services, clinical outcomes and skills in handling

international patients. This pilot project has been launched for about six months. Initially it will

cover about 700 group members and their dependents at Serigraph. WellPoint case managers will

coordinate with patients on their travel and medical arrangement with the hospitals in India. All

the financial details will be looked after by Serigraph's insurer, Anthem Blue Cross and Blue Shield.

The employer-funded healthcare plan will cover the costs of airfare and accommodations, as well

as a dedicated case manager to coordinate travel, medical care plus post-operative care upon

return to U.S.

2.2.2 Ethical Legal aspects of Medical Tourism

Traveling outside their home country for medical care, medical tourists may encounter unfamiliar

ethical and legal issues. While some countries currently presenting themselves as attractive

medical tourism destinations provide some form of legal remedies for medical malpractice, these

legal avenues may be unappealing to the medical tourist. It problems arise, patients might not be

13 http://healthcare.financialexpress.com/200902/market10.shtml

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covered by adequate personal insurance or might be unable to seek compensation via malpractice

lawsuits. Hospitals and/or doctors in some countries may be unable to pay the financial damages

awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not

possessing appropriate insurance cover and/or medical indemnity14. Since medical tourism is

aimed at attracting foreigners, local masses in developing economies do not get equal access to

healthcare facilities. The cost of medical services in these countries is sometimes beyond the reach

of local population, resulting in a lack of ethical fairness towards the locals (Prem, 2010).

Also, technologies like Stem Cell treatment is banned in the United States owing to the unethical

perspective from which it is viewed. Hence, the credibility of such a practice is again questionable

to a certain extent. Legal and Ethical issues have marred the popularity of medical tourism to a

large extent. However, to its credit, the sector has continued to grow at a steady rate. A prospective

medical tourist should also be aware of possible legal issues. There is presently no international

legal regulation of medical tourism. All medical procedures have an element of risk. The issue of

legal recourse for unsatisfactory treatment across international boundaries is a legally undefined

issue at present.

Medical tourism has received an increasing amount of attention from the media, there has been a

remarkably little commentary about medical tourists who have fallen victim to medical

malpractices abroad. For these unlucky patients, the website for India’s largest medical-tourism

hospital, Apollo, presents a grim message: “A prospective medical tourist should also be aware of

possible legal issues. There is presently no international legal regulation of medical tourism. All

medical procedures have an element of risk. The issue of legal recourse for unsatisfactory treatment

across international boundaries is a legally undefined issue at present.”

About medical brain drain and medical tourism, the Director of the WHO’s Human Resources for

Health Department, Dr. Manuel Dayrit noted: ‘Although there are no ready figures that can be

cited from studies, initial observations suggest that medical tourism dampens external migration

14 http://en.wikipedia.org/wiki/Medical_tourism

26

but worsens internal migration.’15 Internal brain drain occurs within nations because physicians

prefer practicing in cities rather than rural regions and affluent rather than impoverished areas.

In India, the internal brain drain phenomenon has been compounded by for-profit private

hospitals offering better reimbursement rates or salaries to physicians and specialists than public

hospitals. Consequently, highly qualified and skilled doctors and specialists tend to gravitate

towards such facilities, leaving public hospitals short-staffed. Facilities that cater to paying

American and other foreign patients are able to attract the cream of the crop of health

professionals by offering them higher pay than local public facilities for the poor or even hospitals

that cater to India’s middle class. American patients should not patronize medical tourism facilities

in India, because in doing so they encourage that nation’s internal medical brain drain. While this

may appear to be a supererogatory duty for them, it is not. It qualifies as an obligatory duty

because of their government’s espousal of the adoption of neoliberalism by poorer countries like

India.

Patient Safety in Medical Tourism

Through literature review and experts opinion on various medical tourism conference and

workshops, Medical Tourism raises quality concerns because patients have to travel before surgery

as well as after surgery. Patient may not receive adequate pre-screening from the foreign provider.

Although the top hospitals often facilitate contact between physicians and foreign patients, these

contacts generally are remote. Physicians can review medical histories, test results, and even

communicate with patients, but they cannot physically examine the patient until he or she arrives.

Countries such as India, Malaysia, or Thailand have different infectious diseases related

epidemiology compared to Europe and North America. Exposure to disease with having built up

natural immunity can be hazard especially Mosquito related diseases and Tuberculosis. Travelling

long distance after surgery increase the risk of complications, long flights and decreased mobility

during the flight back home is a known risk factor for developing blood clots in the legs such as

venous thrombosis or pulmonary embolism. From the past few years the world has seen several

15 I Glenn Cohen, “VIRGINIA JOURNAL OF INTERNATIONAL LAW,” 52 (2011).

27

terrorist attacks both in India and all over the world; this is again a major issue of safety not only

for patient but for general tourist too.

The patients safety and the challenges of seeking care in another country are significant and

require careful consideration. Although some medical tourism firms out relaxing destinations and

amenities, high quality care and patient safety must always be top priorities (Karen, 2009). It is

important to remember that despite medical breakthroughs and an ever- expanding knowledge

base, providing safe, high quality care is a challenge for each and every health care organization

around the world. Health care facilities still struggle to create the systems that achieve effective

care, produce the desired results, and reduce the risk of unwanted outcomes16. Because standards

of care may vary widely from one health care facility to another and from one country to another,

it is important to look for assurances that a health care organization has publicly committed to

provide safe, quality patient care. One of the best known symbols of this commitment is

accreditation, a voluntary process that provides a universal standard of credibility.

Patient’s safety is a fundamental principle of health care. Every point in the process of care-giving

contains a certain degree of inherent unsafely (Gupta, 2008). Adverse events may result from

problems in practice, products, procedures or systems. Patient’s safety improvements demand a

complex system-wide effort, involving a wide range of actions in performance improvement,

environmental safety and risk management, including infection control, safe use of medicines,

equipment safety, safe clinical practice and safe environment of care.

The lapse in safety procedures at the AMRI private hospital in Kolkata, India, which led to the death

of 94 patients and staff in a major, has raised concerns about India's reputation for medical

tourism. Reports in local and national Indian newspapers and television stations have highlighted

the shortcomings in safety standards and monitoring of both public and private hospitals in India.

The toll in the fire is the worst in a hospital in India. Relatives of many of the victims blamed the

private hospital for the absence of safety measures, including emergency exits or functional fire

alarms. Medical staff wanting to smoke habitually turned off fire detectors so they could smoke

inside. According to a national paper, The Times of India, "Most Indian city hospitals may not be

16 Karen H Timmons, “Safety and Quality Standards ~ Driving Patient Expectations”, 2010.

28

fully prepared to handle a disaster of the magnitude of Kolkata hospital blaze. While the fire brigade

admitted it did not carry out regular checks, officials said most hospitals are ill-equipped and do

not follow safety norms, According to the District Fire and Rescue Service department of the 100

Kolkata hospitals, only 33 hospitals have been issued the mandatory fire license." 17The Kolkata

hospital fire has raised concerns across India about the safety standards, monitoring and

accreditation of Indian hospitals. Outside India, the tragedy has received widespread press and

media coverage and will no doubt affect the patient’s confidence in the Indian medical tourism

industry. Patients safety is a new healthcare discipline that emphasizes the reporting, analysis, and

prevention of medical error that often leads to adverse healthcare events Process errors happen

due to administrative errors, investigation errors, treatment errors, communication errors,

payment errors and errors on health workforce management treatment decision.

2.2.3 International Patient Satisfaction and Experience

The measurement of customer satisfaction has become very important for the health care sector

also. The concept of customer satisfaction has encouraged the adoption of a marketing culture in

the health care sector in both developed and developing countries. As large numbers of hospitals

are opening up and the people are becoming more aware and conscious of health, great

competition has emerged in this industry. So to retain their international patients hospitals have

to provide better facilities/services to its customers. Various factors that can affect the patients’

satisfaction include behavior of doctors, availability of specialized doctors, behavior of medical

assistants, quality of administration, quality of atmosphere, availability of modern facilities etc. As

competition is increasing, the hospitals are making their best efforts to provide quality health care

services to its customers. They have begun practicing a patient satisfaction strategy comprising

consumer-oriented plans and policies and practices to genuinely meet the needs of customers.

Also, with increased awareness and high expectations of the customers’ hospitals have to provide

them better facilities. Patients have begun to demand high quality of services i.e. a consumer

oriented approach. And that can be only adapted with the help of standard operating procedures

to tackle the needs of the international patients.

17 http://www.imtj.com/articles/2011/kolkata-private-hospital-tragedy-30120/

29

Customer (Patient) Satisfaction

Many studies have been conducted on customer satisfaction. An attempt has been made to

present in brief, a review of literature on customer satisfaction in general as well as on the

customer satisfaction from hospital services.

As study conducted by IITTM A study of problems and challenges faced by medical tourists visiting

India’ Expectation- Experience Matrix suggests where to invest efforts and resources. At the pre

procedure stage, inbound medical tourists were typically hurt by the fact that the overall cost of

treatment (besides the cost of procedure) was much more than their expectations. Indian medical

tourism draws competitive advantage from quality of procedure that includes competence of

doctors and para-medical staff. Even the quality of clinical infrastructure was found to be good.

One important advantage was that the wait time with Indian healthcare was much less. Also India

receives medical tourists from countries and places that are well connected. At the procedure

stage, the respondents pointed out difficulty with language. There were large numbers of tourists

from Africa and Middle East which are non-English speaking countries. Non-medical staff was not

able to communicate properly. Using interpreters was neither comfortable nor efficient. They were

also disappointed with lodging and boarding facilities. Strengths of Indian medical tourism at the

procedure stage lies with the competence of medical and paramedical staff.

Though various international patient services are offered by various hospitals but there is need of

conducting ground research to know which all services the hospital can offer and up to what level18.

Considering this important study of IITTM the researcher has therefore aim to conduct a study of

international patient’s satisfaction Mumbai, Aurangabad, Pune, Nasik, & Nagpur

2.3 Trends in Medical Tourism

According to a new market report published by Transparency Market Research "Medical Tourism

Market, the global medical tourism market helps in understanding the prominent forces

responsible for the growth of this industry. In addition, the current market

18 IITTM. A Study of Problems and Challenges face by Medical Tourists, 2011

30

dynamics including drivers, restraints, trends, and developments are covered throughout the

report. The research report provides in-depth analysis of the geographies facilitating of inbound

medical services that include India, Thailand, Singapore, Malaysia, Mexico, Brazil, Turkey, Taiwan,

South Korea and prospective countries. Market size estimates and forecast for the period 2011 to

2019 has been given for each of the segments, in terms of USD million, using 2011 as a base year.

Medical tourism trends has been changed, regional medical tourism and domestic medical tourism

has come in market. Medical tourists avoid long distance flight and long distance travel, therefore

medical tourist from US are visiting nearby countries for medical treatment like Costa Rica and

Latin America. Domestic Medical Tourism is another new trend stakeholders are practicing as well.

2.3.1 Domestic Medical Tourism

Domestic Medical Tourism is the practice of travelling from one city to another city or one state to

another state within one’s country for medical care that is either not available in one’s own

neighbourhood or is less expensively available in another neighbourhood. Domestic medical

tourism which is a recent concept in the medical tourism industry is rapidly picking place especially

in USA.

Medical Tourist typology, suggested by Erik Cohen 2010, is based on the extent to which medical

treatments play an important role in tourists’ motivations the trips, First is a ‘Mere Tourists’. This

is an individual who does not make any use of medical services while vacationing in the host

country. Second type is a ‘Medicated Tourist’ who receives medical treatment for health problems

incidentally occurring while in host country.

Domestic medical tourism can help in growth of medical tourism it will also create opportunity to

travel agents and tour operate to start new services. In future, domestic medical tourism will likely

become a new paradigm of how the best medical care can be attained at the lowest cost. Hospitals

will be forced to engage in a new level of competition, reshaping healthcare and cost and

efficiency.

31

Most importantly, with domestic medical tourism, the focus will not only be on cost, but on the

quality of healthcare delivered-a true step in the right direction. ‘Domestic health or medical

tourism is traveling from an individual’s usual place of residence to another within the country for

getting better medical treatment or for want of less expensive treatment available in his/her usual

place of residence’ (Baskhi, Verma) 2012.

Fig 2.2 Domestic Medical Tourism Process

Source: Researcher has constructed process of Domestic Medical Tourism

32

Domestic medical tourism is similar to international medical tourism. There is no requirement for

Medical VISA, Immigration, and other documentation process.

India's international medical tourism industry is now well known, but the first ever figures on

domestic medical tourism are simply staggering. Indians made 126 million domestic trips for

medical purposes, spending over Rs 23,000 crore on such trips, over the span of one year (2008-9)

alone. That, incidentally, is about 30% more than the Union health budget for the same year19.

2.3.2 Benefits of Domestic Medical Tourism

Shorter Distance to be travelled

The distance travelled by domestic tourist is generally less compared to those travelled by

international tourist, thus the inconveniences of long flights are avoided and also there is

requirement of passport and other documentation. In international medical tourism patient used

to travel miles for which made the patient to seat on same position leading to complications. So

it’s always recommended that shorter distance is best option and safe for medical tourist.

Less Documentation Procedure

Compared to international medical tourism very few documents are required related to medical

records and diagnostic reports. Passport, Immigration are not required to cross city or state within

country. The tiring procedures to get medical VISA is also not required.

No language and cultural Barriers

Domestic medical tourism has benefit in home country feeling friendly, especially in the USA

English is spoken nationwide similarly Hindi is spoken in India, so there is no problem at all to

understand and enjoys a homogenous culture. In International medical tourism according to the

MTA , survey, about 70 percent of the survey participants thinks that language was not a barrier,

whereas 29 percent did experienced some language problem occasionally, but in domestic medical

tourism it will not affect their overall experience.

19 Ajay Baksi and A K Verma, “Domestic Medical Tourism in India : Some Facets,” 4 (2013), 29–58 <doi:10.5897/JHMT11.019>.

33

High quality care at affordable cost

Medical tourist travelling another state and city for medical treatment, prices for these procedure

are highly discounted and maybe be as low 15 % to 25 % and without any compromise on the

quality care.

2.3.3 Healthcare Cluster

Cluster is organized by various groups from coming together from different industries to have one

common goal and common message for delivering services. A business cluster is a geographic or

regional absorption of organized business, suppliers, providers and associated institutions in a

particular industry or field. Clusters are considered to increase the productivity with which

companies can complement, compete or work together nationally and globally.

A healthcare cluster or medical cluster is probably the most important single step in establishing a

medical tourism destination and to enhance the location’s chances of success as a destination for

medical tourists and increasing patient flow. All the medical tourism stakeholders, such as

hospitals, doctors, Ministry of Health, Tourism, Economic Development, Tourism Operators, Hotels

and more must work together to promote this image of high quality of healthcare to establish a

“brand” name for the location throughout the world.20 A Healthcare Cluster can adopt and

promote high standards of ethical and professional medical care. These standards will need to be

developed based upon the existing medical requirements and ensure standards for the country,

state, city or region. Marketing standards and goals for the cluster need to be evaluated and

designated to the appropriate entity or groups. Advertising budgets need to be developed with

the Department of Tourism and Department of Health for governmental support.

20 Medical Tourism Association, Annual Report, 2010

34

The Concept of Free Healthcare Zones

The concept of healthcare zones is very new. This type of zone are usually taxed very lightly or

not at all as a way to encourage economic activity. They are able to offer lower operating costs,

which is attractive to medical tourists and investors. Another important factor for those

developing these zones is that they will not have to pay duties on importing the equipment.21

In addition to the tax reliefs, these zones will host many other benefits for patients and investors

like Foster economic development & investment in healthcare infrastructure. Establish world-class

medical clusters of hospitals, life sciences and medical research and education. Foster international

standards and excellence and Serve patients locally, regionally and internationally. The plan for

this free healthcare zone was to actualize the concept of a unique free healthcare zone which

would be the center of clinical, educational and research excellence globally as well as in the region.

The project was supported by the Government of respective countries, and the establishment of a

corporate governance infrastructure, central to the free zone status is made up of comprehensive

regulations, rules, policies, standards and guidance, designed to guarantee the delivery of world-

class qualitative healthcare related services within the free zone.

2.3.4 Healthcare & Medical Tourism Education

The medical tourism market has evolved from its initial days as a grassroots movement to the

global phenomenon, with ever increasing patient streams worldwide. This demands also needs

more expertise and knowledge production in which academic institutions could play a supporting

role in view of the patient and providers.

This increasing number of patients who travel for health reasons has led to the foundation of the

Medical Tourism Association and the European Medical Tourism Alliance they were founded in

order to explore and resolve all relevant issues concerning the new global health market. As of

now, there is not an adequate postgraduate qualification program available for those professionals

working within this industrial sector, there is an academic community supporting this field with

applied knowledge and tools. Creation of a postgraduate qualification program is the aim of a new

21 Researcher had online discussion with medical tourism expert on LinkedIn

35

initiative developed by several leading European universities and cooperating companies, and will

be supported by the two above mentioned organizations. The development of healthcare

management as a career field has received a big boost from the booming corporatization and

growth of hospitals and healthcare delivery organizations in India in recent years. This is an exciting

time for healthcare management in India. Healthcare is changing more rapidly than almost any

other field. The field is changing in terms of how and where care is delivered, who is providing

those services, and how that care is financed. Healthcare management requires talented people

to manage the changes taking place. Some Indian Government Universities as well private

institution has started healthcare Management, Hospital Management, Medical Tourism under

Graduate (UG) and Post Graduate (PG) courses and degrees. Some Universities having PhD

research in healthcare Management and medical tourism like All India Institute of Medical Science,

Delhi and Dr. Babasheb Ambedkar Marathwada University, Aurangabad.

36

2.4 Other Forms of Medical Tourism

2.4.1 Wellness Tourism

Wellness is the adequate method for health prevention and preservation in an aging society.

Wellness supports the trend of individualization, because wellness helps to discover one’s own

personality and the ability to spend time with oneself and his/her appearance. Wellness, in its

holistic aspect, can offer a wide range of different services. Multi optional Consumers can choose

between relaxation, mental training, different kinds and intensities of sport offerings and beauty

treatments. Wellness tourism can constitute an opportunity to combine fun, entertainment and

adventure with health care with the goal of building up strengths for everyday life. Finally wellness

may be considered as an opportunity to find a desired life balance between family, job and

environment (Horx 2001).

In 1948 the WHO (World Health Organization) defines health as a state of complete physical,

mental and social well-being and not only the absence of disease. Classical medicine moved from

a cure to a prevention orientation (Nefiodow 1996, Müller and Lanz 1998). People need self-

responsibility to maintain their vitality (Nahrstedt 2002). Wellness vacations can be considered as

the best possibility to satisfy the needs of the “new tourist”

Wellness Tourist: Wellness Tourist are those generally seeking integrated wellness and prevention

approaches to improve their health/quality of life.

As medical tourism and wellness tourism markets become more crowded and competitive, it will

become increasingly important for countries to differentiate themselves around factors other than

cost and quality. Wellness tourism deals with healthy people who care about health and fitness

and focus on more preventive activities during journey. However it is often hard to divide the

categories of health care tourism, medical tourism and wellness tourism, because it is easy for

destinations of healthcare, medical, and wellness tourism to provide similar healthy services such

as massage, yoga practice, spa and healthy foods (Hun Kim, Batra, 2009,)

37

The health and wellness tourism industry, broadly defined, includes products and services made

accessible to people travelling from their place of residence for health reasons. In addition to

conventional healthcare (medical), this definition encompasses health & wellness, spa tourism,

convalescent addiction treatment, retirement communities, and some alternative health services

(World Bank, 2005).

2.4.2 Alternative Medicine

As an expert rightly pointed out, “The study of the history of alternative medicine is fascinating on

a variety of levels, not just concerning other and often better ways of preserving and restoring

health.22” The history of alternative medicine can be traced back to some 5000 years, when the

Chinese and Indians discovered traditional and Ayurvedic therapies to heal the body and the mind.

Alternative medicine claims some traditional medical practitioners, given its perceived advantages

over the modern medical techniques and the expensive western medicines, alternative medical

therapy is gaining ground in many developing as well as developed countries. Practices like

Ayurveda and Homeopathy claim that surgery may always be the last option in case of treatment

of an ailment.

22 Sunita W, “Complenetray and Alternative Medicine.”

38

Ayurveda

Ayurveda evolves from one of the 4 basic Scriptures (Artharvana Veda), dealing only with the Life

of Humans and Nature in total. Ayurveda was first recorded in the Veda, the world's oldest existing

literature. The three most important Veda texts containing the original and complete knowledge

of Ayurveda, believed to be over 1200 years old, are still in use today. These Ayurvedic teachings

were customarily passed on orally from teacher to student for over 1000 years. Different Era’s in

the History Indian rulers and the wide spread of Ayurveda by Scholars have brought in a change in

way Ayurveda is practiced today. Nalanda and Takshashila, the well-known Universities of the 500

AD and 200 AD respectively, have been the center for transcription of Ayurveda texts and Vedas

into various different languages and records to be the center for debates and discussions with

various scholars from different regions be it far east or far west.

The Buddhist Philosophy had a greater influence on Ayurveda practice to be “nonviolent”, hence

Ayurveda was promoted to be major herbal medicine practice and not adhering the surgical

practices which were considered violence23. Sushrut and Samhita together with Charaka Samhitā,

served as the textual material within the ancient Universities of Takshashila and Nalanda. These

texts are believed to have been written around the beginning of the Common Era, and are based

on a holistic approach rooted in the philosophy of the Vedas and Vedic culture.

The core of Ayurveda practice is that the functioning of all creation, the mineral, plant and animal

kingdoms, can be understood as the interactions of three fundamental energy complexes

(DOSHAS). The three energies are vata, pitta and kapha – signifying the dynamic or mobile,

energetic, nonmaterial aspect of nature; the transformative, intelligence aspect; and the

structural, physical aspect respectively.

2.5 Healthcare Scenario and Medical Tourism in India

Under the Indian Constitution, health is a state subject. Each state therefore has its own healthcare

delivery system in which both public and private (for profit as well as nonprofit) actors operate.

While states are responsible for the functioning of their respective healthcare systems, certain

23 India will emerge top destination in Wellness Tourism by 2017 Published on : Wednesday, October 9, 2012

39

responsibilities also fall on the federal (Central) government, namely aspects of policy-making,

planning, guiding, assisting, evaluating and coordinating the work of various provincial health

authorities and providing funds to implement national programmes. The organization at the

national level consists of the Union Ministry of Health and Family Welfare (MoHFW).

In each State, the organization is under the State Department of Health and Family Welfare that is

headed by a State Minister and with a Secretariat under the charge of the Secretary/Commissioner

(Health and Family Welfare) belonging to the cadre of Indian Administrative Service (IAS).The

Indian systems of medicine consist of both Allopathy and AYUSH (Ayurveda, Yoga, Unani, Siddha

and Homeopathy). Each regional/zonal set-up covers 3–5 districts and acts under authority

delegated by the State Directorate of Health Services. The district level structure of health services

is a middle level management organisation and it is a link between the State and regional structure

on one side and the peripheral level structures such as Primary Healthcare (PHC) and Sub-Centre

on the other.

Indian Healthcare Market: The healthcare market is split into five segments

Table 2.3 Indian Healthcare Market

1. Hospital Government Hospitals - includes healthcare centres, district hospitals and General hospital Private Hospitals - includes nursing homes, mid-tier, and top-tier private hospitals.

2 Pharmaceutical

Includes the manufacture, extraction, processing, purification, and packaging of chemical materials to be used as medications for humans or animals

3 Diagnostics

Comprises businesses and laboratories that offer analytic or diagnostic services including body fluid analysis

4 Medical Equipment and Supplies

Includes establishments primarily engaged in manufacturing medical equipment and supplies, such as surgical, dental, orthopaedic, ophthalmologic, and laboratory instruments, etc.

5 Medical Insurance

Includes health insurance and covers an individual’s hospitalization expenses and medical reimbursement facility incurred due to sickness.

Source: India Brand Equity Foundation

40

Healthcare has become one of India's largest sectors both in terms of revenue and employment.

Out of the total healthcare revenue in the country, hospitals account for 71 per cent,

pharmaceuticals 13 per cent, medical equipment and supplies 9 per cent, medical insurance 4 per

cent and diagnostics 3 per cent. The healthcare sector of India is estimated to reach US$ 100 billion

by 2015, growing 20 per cent year-on-year (y-o-y), as per the rating agency Fitch. 24The industry is

expected to touch US$ 280 billion by 2020, on the back of increasing demand for specialized and

quality healthcare facilities.

According to the Investment Commission of India, the healthcare industry in India has experienced

remarkable evolution of an added 12 per cent per year during the last 4 years, driven by a number

of factors such as increase in the average life expectancy and average income levels, and rising

awareness for health insurance among consumers.

2.5.1 Healthcare Infrastructure in India

According to World Health Organization (WHO) statistics, there are over 250 medical colleges in

the modern system of medicine and over 400 in the Indian system of medicine and homeopathy

(ISM&H). India produces over 250,000 doctors annually in the modern system of medicine and a

similar number of ISM&H practitioners, nurses and Para professionals. Better policy regulations

and the establishment of public private partnerships are possible solutions to the problem of

manpower shortage. India faces a huge need gap in terms of availability of number of hospital beds

per 1000 population. With a world average of 3.96 hospital beds per 1000 population. India stands

just a little over 0.7 hospital beds per 1000 population. Moreover, India faces a shortage of doctors,

nurses and paramedics that are needed to propel the growing healthcare industry. India is now

looking at establishing academic medical centres (AMCs) for the delivery of higher quality care with

leading examples of The Manipal Group & All India Institute of Medical Sciences (AIIMS) already in

place.

24 India Brand Equity Foundation, Healthcare August 2012, 2012, pp. 1–34.

41

The Government of India has decided to increase health expenditure to 2.5 per cent of gross

domestic product (GDP) by the end of the Twelfth Five Year Plan (2012-17)25. Dr Manmohan Singh,

the Prime Minister of India, also emphasized the need for increased outlay to health sector during

the Twelfth Five Year Plan. Moreover, 100 per cent FDI is permitted for health and medical services

under the automatic route. In a recent initiative, 348 essential medicines will now come under

price control in India. These currently contribute Rs 13,033 crore (US$ 2.25 billion) to the total

annual sales of Rs 72,762 crore (US$ 12.59 billion), according to market research firm IMS Health’s

analysis. Some highlights of the Union Budget 2013-14 presented by Mr. P Chidambaram, Minister

of Finance, Government of India, for the healthcare are as follows

The Ministry of Health & Family Welfare has been allocated Rs 37,330 crore (US$ 6.46 billion). Of

this, the new National Health Mission that combines the rural mission and the proposed urban

mission will get Rs 21,239 crore (US$ 3.67 billion), an increase of 24.3 per cent over the RE Rs 4,727

crore (US$ 817.82 million) for medical education, training and research The National Programme

for the Health Care of Elderly is being implemented in 100 selected districts of 21 States. Eight

regional geriatric centers are being funded for the development of dedicated geriatric

departments. Rs 150 crore (US$ 25.95 million) have been provided for National Programme for the

Health Care of Elderly.

Ayurveda, Unani, Siddha and Homoeopathy are being mainstreamed through the National Health

Mission and Rs 1,069 crore (US$ 184.95 million) has been allocated to the Department of AYUSH

Moreover, Rs 1,650 crore (US$ 285.47 million) was allocated for six AIIMS-like institutions. In

addition the central and state government also has some schemes for promotion of wellness

tourism.

The private sector accounts for more than 80% of total healthcare spending in India. Unless there

is a decline in the combined federal and state government deficit, which currently stands at roughly

9%, the opportunity for significantly higher public health spending will be limited. Investment in

25 India Brand Equity Foundation.

42

healthcare Infrastructure is set to rise with both ‘hard’ (hospitals) and ‘soft’ (R&D, education).

Infrastructure is set to benefit Medical tourism as one of the emerging and most lucrative

investment areas in the country

Fig 2.3 Healthcare Service Providers in India

Source: Researcher has frame structure from various report and research paper

Table 2.4 List of NABH Hospitals in India

43

1 B.M. Birla Heart Research Centre,

Kolkata

26 P.D. Hinduja National Hospital and

Research Centre, Mumbai

2 MIMS Hospital (MIMS Ltd.), Calicut 27 N.M. Virani Wockhardt Hospital, Rajkot

3 Kerala Institute of Medical Science,

Thiruvananthapuram,

28 Godrej Memorial Hospital, Mumbai

4 Max Super Speciality Hospital, New

Delhi

29 Fortis Flt. Lt. Rajan Dhall Hospital, New

Delhi

5 Max Super Speciality Hospital (A Unit of

Devki Devi Foundation), New Delhi

30 Kasturba Hospital, Manipal (Renewal

under process), .

6 Moolchand Hospital, New Delhi 31 General Hospital , Gandhinagar

7 Narayana Hrudayalaya, Bangalore 32 Escorts Hospital and Research Centre

Ltd., Faridabad

8 Dr. L. H. Hiranandani Hospital, Mumbai 33 Ruby Hall Clinic, Pune

9 Fortis Hospital, Noida 34 Sterling Hospitals, Vadodara,

10 Columbia Asia Medical Centre - Hebbal,

Bangalore

35 Artemis Health Institute , Gurgaon

11 Manipal Hospital, Bangalore 36 Sparsh Hospital, Bangalore,

12 Nethradhama Superspeciality Eye

Hospital, Bangalore

37 Apollo Speciality Hospital, Chennai

13 Baby Memorial Hospital , Calicut 38 Shalby Hospitals, Ahmedabad

14 Escorts Heart Institute And Research

Centre, New Delhi

39 Wockhardt Hospital, Bhavnagar

(Renewal under process), .

15 Sir Ganga Ram Hospital, New Delhi 40 Fortis Hospitals Ltd., Kalyan

16 Fortis Escorts Hospital, Jaipur 41 Wockhardt Hospitals Ltd., Nashik,

17 Fortis Hospital, Mohali 42 K.G. Hospital, Coimbatore

18 Dharamshila Hospital and Research

Centre, Delhi

43 Holy Spirit Hospital, Mumbai (Renewal

under process), .

19 Chacha Nehru Bal Chikitsalaya, New

Delhi

44 Batra Hospital and Medical Research

Centre, New Delhi

44

20 Kailash Hospital and Heart Institute,

Noida

45 PSG Hospitals,Coimbatore(Renewal

under process), .

21 Sterling Hospitals , Ahmedabad 46 Frontier Lifeline Hospital, Chennai

(Renewal under process), .

22 Amrita Institute Of Medical Sciences,

Kochi

47 B.L. Kapur Memorial Hospital, New

Delhi (Renewal under process), .

23 Apollo Speciality Hospitals, Madurai 48 Global Hospitals & Health City, Chennai

24 Paras Hospitals, Gurgaon 49 Yashoda Super Speciality Hospital,

Kaushambi, Ghaziabad

25 Wockhardt Hospitals Ltd, Nagpur 50 Jeewan Nursing Home & Hospital, Pusa

Road, New Delhi

51 Pushpanjali Crosslay Hospital,

Ghaziabad

76 Apollo Hospitals, Noida

52 Yashoda Hospital, Secunderabad 77 Malabar Institute of Medical Sciences

Ltd., Kerala

53 Holy Family Hospital, Mumbai 78 Narayana Hrudayalaya Hospitals,

Bangalore

54 Primus Super Speciality Hospital,

Chanakyapuri

79 Yashoda Super Speciality Hospital,

Malakpet, Hyderabad

55 Max Hospital, Gurgaon 80 Sarvodaya Hospital & Research Centre,

Faridabad

56 Dr. Ram Manohar Lohia Combined

Hospital, Lucknow

81 Asian Institute of Medical Sciences,

Faridabad

57 Vijaya Medical & Educational Trust,

Chennai

82 Dr. Balabhai Nanavati Hospital,

58 General Hospital, Ernakulum 83 Desun Hospital & Heart Institute,

Kolkatta

59 Lilavati Hospital and Research Centre,

Mumbai

84 Jeewan Mala Hospital Pvt. Ltd. , New

Delhi

45

60 Apollo Hospitals International Limited,

Gandhinagar

85 Mallya Hospital, Bangalore

61 Max Super Specialty Hospital,

Patparganj, New Delhi

86 Care Hospital (A Unit of Ganga Care

Hospital Pvt. Ltd.), Nagpur

62 Metro Hospital & Heart Institute, Sec.

12, Noida

87 Narayana Nethralaya Superspeciality

Eye Hospital (NN2), Bangalore

63 Delhi Heart & Lung Institute, New Delhi 88 Bangalore Baptist Hospital, Bangalore

64 Dr's Mehta Hospitals Pvt. Ltd., Chennai 89 Krishna Institute of Medical Sciences

Ltd., Secunderabad

65 Columbia Asia Hospital, Gurgaon 90 Park Hospital, New Delhi

66 Medanta - The Medicity, Gurgaon 91 Geetha Multi Speciality Hospital,

Secunderabad

67 Metro Hospital & Cancer Institute, 92 Care Hospital, Nampally, Hyderabad

68 District Government Head Quarters

Hospital, Namakkal

93 National Heart Institute, New Delhi

69 Rainbow Children's Medicare Pvt. Ltd.,

Hyderabad

94 Baroda Heart Institute & Research

Centre, Vadodara

70 Columbia Asia Referral Hospital-

Yeshwanthpur, Bangalore

95 Sahyadri Speciality Hospital, Pune

71 Star Hospitals (A Unit of Unimed

Healthcare Pvt. Ltd.), Hyderabad

96 Bankers Heart Institute, Vadodara

72 Fortis Escorts Hospital, Amritsar 97 Rabindranath Tagore International

Institute of Cardiac Sciences, Kolkata

73 VGM Hospital, Coimbatore 98 Sri Balaji Action Medical Institute

74 LV Prasad Eye Institute, Hyderabad 99 Medical Trust Hospital, Cochin

75 Fortis Hospital Limited, Nagarbhavi,

Bangalore

100 Vikram Hospital Private Limited, Mysore

101 Care Hospital, Surat 126 Prime Hospitals, Ameerpet,

Hyderabad

102 Apollo Hospitals, Secunderabad 127 Guru Nanak Care Hospital, Hyderabad

46

103 Metro Hospital & Heart Institute,

Lajpat Nagar, New Delhi

128 GEM Hospital & Research Centre Pvt.

Ltd., Coimbatore

104 RLKC Hospital, Metro Heart Institute,

New Delhi

129 Bhandari Hospital & Research Centre,

Jaipur

105 Care Hospital , Ramnagar,

Visakhapatnam

130 Kovai Medical Center and Hospital,

Coimbatore

106 Hospital for Mental Health, Vadodara 131 Rajiv Gandhi Cancer Institute &

Research Centre, New Delhi

107 Jupiter Hospital, Thane (West) 132 Yashoda Hospital & Research Centre

Ltd., Nehru Nagar, Ghaziabad

108 SK Soni Hospital, Jaipur 133 GBH-American Hospital, Udaipur

109 Government Hospital, Sholingur 134 Yashoda Super Specialty Hospital,

Somajiguda, Hyderabad

110 Trichur Heart Hospital Limited, Trichur 135 Fortis Hospital, Shalimar Bagh, New

Delhi

111 Nidhi Hospital , Ahmedabad 136 Metro Heart Institute with

Multispeciality, Faridabad

112 IVY Hospital, Mohali 137 R G Stone Urology & Laproscopy

Hospital, Kailash Colony, New Delhi

113 Metro Hospital & Heart Institute,

Meerut

138 Regency Hospital, Kanpur

114 Institute of Liver and Biliary Sciences,

New Delhi

139 Usha Mullapudi Cardiac Centre,

Hyderabad

115 Indian Spinal Injuries Center, New

Delhi

140 M.S. Ramaiah Memorial Hospital,

Bangalore

116 Institute of Human Behaviour & Allied

Sciences (IHBAS), New Delhi

141 Aditya Care Hospital, Bhubaneswar

117 Sankara Nethralaya, Chennai 142 B.B.C. Heart Care, Pruthi Hospital,

Jalandhar

47

118 Narayana Nethralaya 1(NN1),

Bangalore

143 Pushpawati Singhania Research

Institute for Liver, Renal & Digestive

Diseases, New Delhi

119 Apex Hospitals Pvt. Ltd., Jaipur 144 Grecian Super Speciality Hospital,

Mohali

120 Kamineni Hospitals Pvt. Ltd., L.B.

Nagar, Hyderabad

145 Govt. Women & Children’s Hospital,

Thiruvanthapuram

121 Saket City Hospital, New Delhi 146 Action Cancer Hospital, New Delhi

122 Omega Hospital, Hyderabad 147 Hospital for Mental Health,

Ahmedabad

123 Fortis Hospital Ltd. Bannerghatta

Road, Bangalore

148 Sunshine Hospitals, Secunderabad

124 Health Care Global – Speciality Centre,

Bangalore

149 N.M. Wadia Institute of Cardiology,

Pune

125 Khandelwal Hospital & Urology

Centre, New Delhi

150 Taluk Head Quaters Hospital,

Cherthala, Alappuzha

151 Nagarjuna Hospital, Vijayawada 176 Heart & General Hospital, Jaipur

152 Sree Renga Hospital, Chengalpattu,

Tamil Nadu

177 Jaslok Hospital & Research Centre,

Mumbai

153 Lotus Childrens Hospital, Hyderabad 178 HCG Multi Speciality Hospital,

Ahmedabad

154 Ramkrishna Care Hospital, Raipur 179 Sathya Kidney Centre & Super

Speciality Hospital, Hyderabad

155 Ganga Medical Centre & Hospitals Pvt.

Ltd., Coimbatore

180 Nusi Wockhardt Hospital, Goa

156 Columbia Asia Hospital, Mysore 181 IMS & SUM Hospital, Bhubaneswar

157 Sri Ramachandra Medical Centre,

Chennai

182 Kapoor's Kidney and Urostone Centre

Pvt. Ltd., Chandigarh

158 Nirmal Hospital Private Limited, Surat 183 The Mission Hospital, Durgapur

159 Care Institute of Medical Sciences

(CIMS), Ahmedabad

184 Soni Hospital, Jaipur

48

160 Medica Superspeciality Hospital, kol 185 Jehangir Hospital, Pune,

161 A.J. Hospital & Research Centre,

Mangalore

186 Apollo Hospitals, Bilaspur,

162 Aditya Birla Memorial Hospital, Pune 187 Vadamalayan Hospitals, Madurai

163 Narayana Hrudayalaya - Mallya Reddy

Hospital, Hyderabad

188 Chord Road Hospital Pvt. Ltd.,

Bangalore,

164 Aware Global Hospitals, Hyderabad 189 Bhatia Global Hospital & Endosurgery

Institute, New Delhi

165 Hiranandani Hospital (A Fortis

Associate Hospital), Mumbai

190 Apollo BGS Hospitals, Mysore

166 Fortis Hospital Limited, Kolkata 191 Govt. Head Quarters Hospital,

Padmanabhapuram, Kanyakumari

167 EMS Memorial Co-Operative Hospital

& Research Centre Ltd., Malappuram

168 Saroj Hospital & Heart Institute, Delhi

169 Noble Hospital, Pune

170 Max Superspeciality Hospital,

Shalimar Bagh, New Delhi

171 L.V. Prasad Eye Institute ,

Bhubaneswar

172 NU Hospitals Private Limited,

Bangalore

173 Basavatarakam Indo American Cancer

Hospital and Research Institute

174 Max Superspeciality Hospital, Mohali,

175 Johal Multispecialty Hospital

Source: National Accreditation Board for Hospitals & Healthcare Providers (NABH)

49

Table 2.5 List of JCI Accredited Hospitals in India

Aditya Birla Health Services Ltd. Pune, Maharashtra

Ahalia Foundation Eye Hospital Palakkad/Kerala

Apollo Gleneagles Hospitals, Kolkata Kolkata, West Bengal

Apollo Hospitals Bangalore Bangalore

Apollo Hospitals Chennai Chennai

Apollo Hospitals Hyderabad Hyderabad

Apollo Hospitals Hyderabad - Primary

Stroke Program

Hyderabad

Artemis Health Institute Gurgaon, Haryana

Asian Heart Institute Mumbai

Fortis Hospital, Bangalore ( Was

Wockhardt Hospital, Bangalore)

Bangalore

Fortis Hospital, Mohali Mohali, Punjab

Fortis Hospital, Mulund (Was Wockhardt

Hospital, Mumbai)

Mumbai

Grewal Eye Institute Private Limited Chandigarh

Indraprastha Apollo Hospital New Delhi

Medanta - The Medicity Gurgoan, Haryana

Moolchand Hospital New Delhi

Narayana Hrudayalaya Bangalore-Karnataka

Narayana Multispecialty Hospital, Jaipur Jaipur

Satguru Partap Singh Apollo Hospital Punjab

Sri Ramachandra Medical Centre Chennai, Tamil Nadu

Shroff Eye Hospital Mumbai

50

2.5.2 Medical City Projects in India

India has huge investment in healthcare sector as new trend of global healthcare countries like

Dubai, Turkey, South Korea, Singapore, Thailand have started working on healthcare cluster and

Medical City Projects.

India is also creating medical city projects, many of these projects are in first phase. This phase

features number of beds, super specialty services, multispecialty services and research Centre. The

second phase they is planned for Medical Education Institute and Nursing Institutes. Third phase

is planned for commercial zones and common infrastructure. According to Times of India’s article

the ‘Global Eye on Medical City Project in India, many foreign investor would like to come and start

the project ,John Hopkins, Dubai DM Healthcare have already started some projects with Indian

healthcare service providers.

Here are some projects started from 3-5 years.

Table 2.6 Health city Projects in India

SN Project Location Budget Features

1 Naresh Trehan Medicity Gurgon,

Delhi

1200 Cr 93 acers Land

1600 Beds

Undergraduate , Postgraduate Institute

Medicine & Trauma Care

2 Fortis Medicity Lucknow 1200 Cr 53 acers land

600-800 Beds

Hospital Multispecialty

Hospital Superspciality

Research Centre

UG, PG, Dental & Nursing College

3 Apollo Health city Hyderabad 1000 Cr 33 acers land

700 Beds

Hospital

51

Only Postgraduate College

4 MIOT Medical City Bangalore 1000 Cr Super specialty Hospital

Researcher Center,

5 Dhirubhai Ambani

Health city

Kolkata 1000 Cr Multispecialty Hospital, Healthcare

Institutes,

Research Center,

Accommodation Facilities

6 Cochi Medical City Kochi NA 1000 Beds Multispecialty Hospitals

50 Bed Ayurvedic Hospital

Spa Treatment

Medical College

Convention center

7 Narayana Hrudayala Banglore 250 Cr 250 Neuroscience

Equipped with sate-art-facilities

Cardiology Specialty

8 Elixir Healthcity Hyderabad NA Institute of Gastroenterology

Eye Care

Children Hospital

Medical Tourism

9 West Bengal Healthcity West Bengal 800Cr Superspeicality Hospital

Wellness Tourism

Research Center

Medical Tourism

10

Aster Med city Kerala 21.50

Billion

40 acer land

550 Beds core hospitals with nine center

of excellence

3-5 Start Hotels

Service Apartments

11 CMC Med city Ludhiana 50 Cr 2.3 Lakh Sq. ft area

52

200 Beds Cancer Unit

Diagnostic Center

100-bed speciality unit for crippled childre

12 Odhisa Health city

Odhisaa Project Conceptual Stage Industrial Development

Corporation working

13 Nagpur Health city Nagpur Project Conceptual Stage

Maharashtra Airport Development Company Ltd by

Govt of Maharashtra working

14 Bhubaneswar Healthcity Bhubaneswar State Government concept note of the health city

project has been proposed

15 Aditya Birla Medical City Pune Project Conceptual Stage

Source: Researcher has collected this information through Literature review through online & printed reports and News

2.5.3 Medical Tourism in India

Medical Tourism in India is a combination of several factors which makes India a unique healthcare

destination. Over 60,000 cardiac surgeries are done every year with outcomes at par with

international standards. Multi-organ transplants are successfully performed at 1/10th of the costs

in comparison to the West. Patients from over 55 countries are treated at Indian hospitals. The

Indian healthcare industry is undergoing a phenomenal expansion and India in now looked upon

as the leading country in the promotion of medical tourism, with an annual growth rate estimate

at 30%. India’s top-rated education system provides an estimated 30,000 doctors and nurses each

year and to meet this demand the Indian governments spending on the health care sector is

expected to be around 8% of its GDP in 2012 onwords. Statistics suggest that the medical tourism

industry in India is worth $333 million (Rs. 1,450 crore) while a study by CII-MacKinsey estimates

that the country could earn Rs.5, 000-10,000 crore.

Medical Tourism is an emerging niche segment of Tourism Industry in India. The total Foreign

Tourist Arrivals (FTAs) in India & percentage of foreign tourists who came for the purpose of

Medical Treatment during the period 2009 to 2011 is as follows.

53

Table 2.7 Foreign Tourist arrivals for Medical Treatment26

2009 2010 2011

Total FTAs

(in numbers)

Total no. of Foreign

tourists who came

for medical

treatment

Total FTAs

(in numbers)

Total no. of Foreign

tourists who came

for medical

treatment

Total FTAs

(in

numbers)

Total no. of

Foreign tourists

who came for

medical

treatment

5167699 113689 5775692 155944 6309222 138803

Source : Press Information Bureau, Government of India

According to Government of India, India’s $17-billion-a-year health-care industry could grow 13

per cent in each of the next six years, boosted by medical tourism, which industry watchers say is

growing at 30 per cent annually27. Probably realizing the potential, major corporate such as the

Tatas, Fortis, Max, Wockhardt, Primal, Reliance, Global, Parkway and the Escorts group have made

significant investments in setting up modern hospitals in major cities.

Many have also designed special packages for patients, including airport pickups, visa assistance

and board and lodging. The major service providers in Indian medical tourism are: the Apollo

Hospitals, Escorts Hospital, Fortis Hospitals, Breach Candy, Hinduja, Mumbai’s Asian Heart

Institute, Arvind Eye Hospitals, Manipal Hospitals, Mallya Hospital, Shankara Nethralaya etc. AIIMs,

a public -sector hospital is also in the fray. In terms of locations – Delhi, Chennai, Bangalore and

Mumbai cater to the maximum number of health tourists and are fast emerging as medical tourism

hubs. are seen primarily within the private/corporate sector, not in the public sector.

Medical tourism in India includes advanced and life savings health care services like open

transplants, cardio vascular surgery, eye treatment , knee/hip different cosmetic surgeries and

alternate systems of medicine. Also leisure aspect medical traveling/wellness tourism may be

included on such medical travel trips. India provides a variety of medical services to overseas

patients.

26 http://pib.nic.in/newsite/PrintRelease.aspx?relid=101717 27 CII, “Great Advantage in India Medical Tourism”, 2004.

54

Baxi (2004) observed according to the Confederation of Indian Industry (CII), India has the potential

to attract 1million tourists per annum, which could contribute up to $5 bn to the economy. India

must leverage its competitive edge, especially its cost advantage. India offers a unique basket of

services to an individual that is difficult to match by other countries. Mukherjee and Mookerji

(2004) mentioned that after Singapore and Thailand, India may be the next multi- million dollar

Asian medical industry. Apollo hospitals group, Wockhardt, Escorts, Fortis, Hinduja and Breach

Candy are some of the names in healthcare that have come forward to tie up with tourism industry

players like Hyatt, Kuoni, Indian Airlines and Bangladeshi carrier GMC to offer discount-laced

customized packages to international medical tourist to India.

India has tremendous potential for medical tourism. Many private players are ready to tap this

opportunity but there is need of proper organisation and management of medial tourism in India.

India characterizes the most potential medical tourism market in the world. Features such as low

cost, scale and range of treatments provided by India differentiates it from other medical tourism

destinations. Additionally, the growth in India’s medical tourism market will be a boon for several

associated industries, including hospital industry, medical equipment’s industry and

pharmaceutical industry.