healthcare telemedicine and medical tourism in india

8/12/2019 Healthcare Telemedicine and Medical Tourism in India

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A

BRIEF REPORT

ON

HEALTHCARE, TELEMEDICINE & MEDICAL TOURISM

IN INDIAOctober 2013


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A brief report on Healthcare, Telemedicine & Medical Tourism in India

Private & Confidential Page 2of 19

SECTION-I

HEALTHCARE INDUSTRY


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OVERVIEW OF HEALTHCARE INDUSTRY

1.1 IntroductionThe Healthcare sector, in India, is at an inflection point and is poised for rapid growth in the

medium term. However, Indian healthcare expenditure is still amongst the lowest globally and there

are significant challenges to be addressed both in terms of accessibility of healthcare service and

quality of patient care. While this represents significant opportunity for the private sector, the

Government can alsoplay an important role in facilitating this evolution.

The healthcare industry includes medical care providers, physicians, specialist clinics, nursing homes,

hospitals, medical diagnostic centers, and pathology laboratories. In terms of revenue and

employment, healthcare is one of Indias largest service-sector industries. During the 1990s, Indian

healthcare grew at a compound annual rate of 16%. The total value of the sector is more than$34

billion. This translates to $34 per capita, or roughly 6% of GDP. The Indian health care industry was

valued at US$ 79 billion in 2012, and is expected to reach US $160 billion by 2017. The Indian

healthcare sector is expected to grow at about 15 percent year-on-year (y-o-y), on account of factors

such as rapid growth in infrastructure development, creation of demand for higher levels of

healthcare, rising awareness of end users, and launch of innovative insurance, reimbursement, and

financing policies.

Healthcare spending in India accounts for over 5 per cent of the country's GDP. Out of this, the

public spending in percentage is around 1 per cent of GDP. The presence of public health care is

not only weak but also under-utilized and inefficient. Meanwhile, private sector is quite dominant in

the healthcare sector. Around 80 percent of total spending on healthcare in India comes from the

private sector. Inadequate public investment in health infrastructure has given an opportunity to

private hospitals to capture a larger share of the market. In addition the demand for hospital services

has been increasing due to the rise in lifestyle related diseases.

1.2 Indian Healthcare Industry Trends Healthcare sector has witnessed positive upward trend even during recession Reports suggest that healthcare is going to be one of the major sector that would fuel theeconomic growth and will contribute to the increased revenues, along with IT Services and

Education sectors,

According to the All India Management Association in collaboration with BostonConsulting Group and the Confederation of Indian Industries (CII) together in their IndiasNew Opportunities- 2020, they have also forecasted 40 millions new jobs and around 200billion increased revenues by 2020.

The Indian healthcare industry has witnessed a massive spurt in healthcare spend and is expected to

reach US$100billion by 2015 from the current ~US$65 billion, growing at a CAGR of 20% a year

Revenues from the healthcare sector account for 5.2 percent of the GDP, making it the third largest


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growth segment in India. The Indian healthcare market is currently estimated at US$ 34.2 billion.

Healthcare revenue in India is set to reach US$ 280 billion by 2020; expenditure is likely to grow at a

compound annual growth rate (CAGR) of 12 per cent over 2012-15. Rising incomes, greater healthawareness, lifestyle diseases, and increasing insurance penetration will contribute to growth.

Healthcare delivery and pharmaceuticals account for nearly 75% of the total healthcare market. India

has only 0.7 beds per 1,000 people, far below the global average of 2.6.India needs to add 2 million

beds to the existing 1.1 million by 2027, and requires immediate investments of $82 billion to make

up for its infrastructure deficit.

The Indian healthcare industry is poised to grow at a compounded annual growth rate of 15 per

cent. Nearly 90 per cent of this growth will come from the private sector. In India, private

healthcare accounts for almost 68 percent of the countrys total healthcare expenditure. Funds in the

Indian healthcare sector have been largely private. The private sector provides 60 per cent of alloutpatient care in India and as much as 40 percent of all in-patient care. It is estimated that nearly 70

per cent of all hospitals and 40 per cent of hospital beds in the country are in the private sector. The

health insurance is growing steadily but profitability is a challenge because of the high claims and

other commission and management expenses. It expects 20 per cent growth in business to Rs 150

billion in 2013-14.

The investments in medical and surgical instruments segment is amount to US$115.29 million over

the period August 1991 to April 2007. The healthcare equipment sector attracted 8.8 per cent of the

total investments in terms of deal value with an aggregate of US$ 249.01 million (20 deals). The

hospital and diagnostics centres in India received foreign direct investment (FDI) worth US$1,597.33 million, while drugs & pharmaceutical and medical & surgical appliances industry registered

FDI worth US$ 10,318.17 million and US$ 622.99 million, respectively during April 2000 to March

2013.

In 2006, imports of medical equipment and supplies were valued at US$1,125.8million, an increase

of 21.7% over 2005.The healthcare sector attracted US$ 379 million in 2007 which is 6.8 percent of

the total private equity (PE) investment of US$ 5.93 billion.


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71%

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Marketbreakupbyrevenues(2012E)

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MedicalInsuranceDiagnostics

2. MARKETVIEW OF INDIAN HEALTHCARE SECTOR2.1 The Indian healthcare Industry

The Indian healthcare industry is seen to be growing at a much rapid pace than it wasanticipated before and is expected to become a USD 250 billion by 2020.

According to the Investment Commission of India the healthcare sector has experiencedphenomenal growth of more than 12 percent per annum in the last four years

This growth is expected to be driven by a number of factors: rising life expectancy, risingincome levels of Indian households, increasing penetration of health insurance and risingincidence of lifestyle-related diseases in the country has led to increased spending onhealthcare delivery.

2.2 Current Size of the Healthcare Industry The Indian Healthcare sector currently represents a USD 40 Billion industry. A break-up of

the sector of 2012 is provided:

Indias healthcare spend is significantly low when compared to the global, developed andother similar emerging economies.

The Indian healthcare spend is less than half the global average in percentage terms whencompared on a percent of GDP basis.


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As is noted from the comparison below, Private Sector contribution to the healthcare sector at 75 %

is amongst the highest in the world in percentage terms. Public spending, on the other hand,

isamongst the lowest in the world and is 23% points lower than the global average.


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2.6 Healthcare infrastructure deficienciesThe penetration of healthcare infrastructure in India is much lower than that of developed countries

and even lower than the global average.

2.7 Current InfrastructureThe healthcare infrastructure in India is inadequate compared with the global standards. It lags

behind the global average in terms of healthcare infrastructure and manpower. India has an average

0.6 doctors per 1000 population against the global average of 1.23 17 which suggests an evident

manpower gap.

INDICATORS YEAR* INDIA USA UK BRAZIL CHINA

Hospital Bed

Density(per 10000population)

2000-2010 12 31 39 24 30

Doctor Density(per

10000population)

2000-2010 6 27 21 17 14

Births attendedby

skilled healthpersonnel

(percent)

2000-2010 47 99 NA 97 98

No of doctors 2010 6,43,520 7,93,648 1,26,126 3,20,013 18,62,630

No. of Nurses 2010 13,72,059 29,27,000 37,200 5,49,423 122,59,240

No. of Dentists 2010 55,344 4,63,663 25,914 2,17,217 1,36,520

Avg. no. ofdoctorsper bed

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2010 1.3 9.8 0.6 2.9 1

* latest year available data


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3. MARKET PLAYERS

3.1 Key Players in the Healthcare Segment:The government's share in the healthcare delivery market is 20% while 80% is with the private

sector. Private players have made significant investments in setting up state-of-the-art private

hospitals in cities like Mumbai, New Delhi, Chennai, and Hyderabad. The following are the major

domestic private healthcare providers in India

3.1.1Apollo Hospitals: Apollo Hospitals has emerged as the single largest private hospital group inSouth Asia. It operates hospitals, dispensaries, clinics, and laboratories. It manages a network of

approximately 41 specialty hospitals and clinics with a bed capacity of over 9,000 across the countryand abroad. It has tied up with insurers like BUPA (UK),Vanbreda (Belgium) and Mondial (France)

It has a joint venture with Singapore based Parkway Group Healthcare PTE Ltd.

3.1.2The Escorts Group: This has a presence in specialized cardiac treatment and multi-specialty carehospitals providing a whole gamut of specialized medical services. Escorts operate ten hospitals

across India. The group is also reputed for tertiary care services such as neurology, neurosurgery,

plastic surgery, and urology. Escorts Heart Institute and Research Centre (EHIRC) has a 325 bed

tertiary care institute, with 9 operation theatres, 5 cath labs, 2 heart command centers and world

class facilities. It has carried out over 80,000 angiographies and 43,000 cardiac surgeries over the past

fifteen years which is a world record

3.1.3Fortis Healthcare: This is a company founded by the promoters of the Indian pharmaceuticalmajor, Ranbaxy Laboratories, started operations in 2001. It has approximately 12 hospitals with

1,900 beds. It has operations across North India in the cities of Delhi, Noida, Mohali, Amritsar,

Faridabad, Raipur, and Srinagar. Ithas a joint venture with Real Estate player DLF to set up

hospitals across the country with an investment of about US$ 1.5 billion

3.1.4Max Healthcare:This is a fully owned subsidiary of the highly diversified Max Group, with a chainof clinics and hospitals with a bed capacity of 1200. On an average, Max Healthcare treats 30,000

patients every month, with 200 new patients visiting the facilities every day. It has collaborated with

Singapore General Hospital in the areas of medical practices, nursing, paramedical research andtraining.

3.1.5Wockhardt: This is among Indias leading pharmaceutical and healthcare companies. Sinceinception in 1989, the Wockhardt Hospital & Heart Institute has become a renowned tertiary level

heart centre providing cardiac care to patients of all age groups. It is the first recognized hospital in

South Asia on the worldwide panel of Blue Cross blue Shield, the largest provider of health

insurance in USA. It has approximately 10 hospitals with 1,500 beds. It has entered into Public-

Private Partnership with the Government of Gujarat to manage the 275-bed Palanpur Civil General

Hospital in Gujarat.


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3.1.6Manipal Health Systems: Its chain consists of approximately 9 primary centres at7 rural locations,8 secondary hospitals at urban and semi-urban locations and 3tertiary hospitals at urban and

semi-urban locations. It has a joint venture with Pantaloon Retail for comprehensive retailhealthcare foray.

3.1.7Aravind Eye Hospital:This hospital in South India is the single largest provider of eye surgery inthe world. In 1998, its hospitals saw 1.2 million outpatients and performed 183,000 cataract

surgeries. It costs Aravind about US$ 10 to conduct a cataract operation. It costs hospitals in the

United States about US$ 1,650 to perform the same operation.

3.2 Foreign collaboration in the Indian Healthcare sector:Since liberalization in 1991, a growing number of Indian companies have formed alliances with

foreign firms. The following are some of such alliances:

Wockhardt collaborated with Harvard Medical International Inc. USA Fortis Healthcare collaborated with Partners Healthcare System, USA Birla Heart & Research Centre collaborated with Cleveland Clinic Foundation, USA Max Healthcare and Singapore General Hospital (SGH) have entered into collaboration for

medical practice, research, training, and education in healthcare services.

Apollo-Gleneagles Hospitals Ltd. Its a 50:50 joint ventures between Apollo Hospitals Ltdand Parkway Group of Singapore. The joint venture is also looking at business opportunitiesoverseas in West Asia and North Africa.

Apollo Hospitals has also entered into a partnership with Yemens Hayel Saeed AnamGroup to provide advisory services to the latters hospital project.

3.3 Foreign players in India: The US-based Atlas Medical Software, which specializes in developing software solutions for

the healthcare industry, has set up its operations in India.

Bayer Diagnostics, one of the largest diagnostic businesses in the world. GE-BEL, a joint venture between General Electricals and Bharat Electronics Limited is the

only manufacturer of X-ray and CT tubes in South Asia.

UK-based Isoft Group plc (iSOFT), one of the worlds leading suppliers of applicationsystems for hospitals and healthcare organizations.

Phillip sells about US$ 43-49 million worth of medical systems in India. The US-based healthcare products major, Proton Health Care is making an entry into India

with its range of digital health monitoring devices.

Siemens is a leading manufacturer of medical equipment with a market share of more than30 per cent in India.

Wipro GE Medical Systems, a joint venture between GE Medical Systems and WiproCorporation, is Indias largest medical systems sales and service provider


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SECTION-II

TELEMEDICINE INDUSTRY


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1. TELEMEDICINE1.1 Introduction

Telemedicine is the use of telecommunication and information technologies in order to provide

clinical health care at a distance. It helps eliminate distance barriers and can improve access to

medical services that would often not be consistently available in distant rural communities. It is also

used to save lives in critical care and emergency situations.

Although there were distant precursors to telemedicine, it is essentially a product of 20th century

telecommunication and information technologies. These technologies permit communications

between patient and medical staff with both convenience and fidelity, as well as the transmission of

medical, imaging and health informatics data from one site to another. Early forms of telemedicine

achieved with telephone and radio have been supplemented with video telephony, advanceddiagnostic methods supported by distributed client/server applications, and additionally with

telemedical devices to support in-home care.

1.2 DisambiguationOther expressions similar to telemedicine are the terms "telehealth" and "eHealth", which are

frequently used to denote broader definitions of remote healthcare not always involving active

clinical treatments. Telehealth and eHealth are at times incorrectly interchanged with telemedicine.

Like the terms "medicine" and "health care", telemedicine often refers only to the provision of

clinical services while the term telehealth can refer to clinical and non-clinical services involving

medical education, administration, and research.


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2.TYPES OF TELEMEDICINETelemedicine can be broken into three main categories: store-and-forward, remote monitoring and

(real-time) interactive services.

2.1.1 Store-and-forward telemedicineIt involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this

data to a doctor or medical specialist at a convenient time for assessment offline. It does not require

the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and

pathology are common specialties that are conducive to asynchronous telemedicine. A properly

structured medical record preferably in electronic form should be a component of this transfer. A

key difference between traditional in-person patient meetings and telemedicine encounters is the

omission of an actual physical examination and history. The 'store-and-forward' process requires theclinician to rely on history report and audio/video information in lieu of a physical examination.

2.1.2 Remote monitoringIt is also known as self-monitoring or testing, enables medical professionals to monitor a patient

remotely using various technological devices. This method is primarily used for managing chronic

diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can

provide comparable health outcomes to traditional in-person patient encounters, supply greater

satisfaction to patients, and may be cost-effective.

2.1.3 Interactive telemedicine services provide real-time interactions between patient and provider, toinclude phone conversations, online communication, and home visits. Many activities such as history

review, physical examination, psychiatric evaluations and ophthalmology assessments can be

conducted comparably to those done in traditional face-to-face visits. In addition, clinician-

interactive telemedicine services may be less costly than in-person clinical visit.


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3. BENEFITS AND USES Telemedicine can be extremely beneficial for people living in isolated communities and

remote regions and is currently being applied in virtually all medical domains. Patients who

live in such areas can be seen by a doctor or specialist, who can provide an accurate and

complete examination, while the patient may not have to travel or wait the normal distances

or times like those from conventional hospital or GP visits. Recent developments in mobile

collaboration technology with the use of hand-held mobile devices allow healthcare

professionals in multiple locations the ability to view, discuss, and assess patient issues as if

they were in the same room.

Telemedicine can be used as a teaching tool, by which experienced medical staff can observe,show, and instruct medical staff in another location, more effective or faster examination

techniques. It improved access to healthcare for patients in remote locations.

Telemedicine has been shown to reduce the cost of healthcare and increase efficiencythrough better management of chronic diseases, shared health professional staffing, reduced

travel times, and fewer or shorter hospital stays. Several studies have documented increased

patient satisfaction of telemedicine over the past fifteen years.

Tele-monitoring is a medical practice that involves remotely monitoring patients who are notat the same location as the health care provider. In general, a patient will have a number of

monitoring devices at home, and the results of these devices will be transmitted via

telephone to the health care provider. Telemonitoring is a convenient way for patients toavoid travel and to perform some of the more basic work of healthcare for themselves.

In addition to objective technological monitoring, most telemonitoring programs includesubjective questioning regarding the patient's health and comfort. This questioning can take

place automatically over the phone, or telemonitoring software can help keep the patient in

touch with the health care provider. The provider can then make decisions about the

patient's treatment based on a combination of subjective and objective information similar

to what would be revealed during an on-site appointment.

Some of the more common things that telemonitoring devices keep track of include bloodpressure, heart rate, weight, blood glucose, and hemoglobin. Telemonitoring is capable of

providing information about any vital signs, as long as the patient has the necessary

monitoring equipment at his or her location. Depending on the severity of the patient's

condition, the provider may check these statistics on a daily or weekly basis to determine the

best course of treatment. The first Ayurvedic telemedicine center was established in India in

2007 by Partap Chauhan, an Indian Ayurvedic doctor and the Director of Jiva Ayurveda.

Teledoc used Nokia phones running Javascript to link mobile ayurvedic field techs with

doctors in the Jiva Institute clinic; at its peak, Teledoc reached about 1,000 villagers per

month in Haryana province, primarily treating chronic diseases such as diabetes.


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SECTION-III

MEDICAL TOURISM IN INDIA


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1. OVERVIEW OF MEDICAL TOURISM1.1 Introduction

Medical tourism (also called medical travel, health tourism, or global healthcare) is a term initially

coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling

across international borders to obtain health care. It also refers pejoratively to the practice of

healthcare providers travelling internationally to deliver healthcare.

India receives hundreds of thousands of tourists that come in to the country to undergo medical

treatments, then leaving the country and going back home. It is called Medical Tourism and it is a

blooming global industry as India has become a main medical tourism hub.This phenomenon of

people traveling across national borders for medical care has existed for centuries. However, only in

the recent decades has it really taken off and fully blossomed, as patients have realized that they have

options other than receiving local medical treatment and it is their right to check elsewhere and take

advantage of the fact that the improvement of the means of transportation along with the internet is

turning our world into a global village.

The major reason people are traveling abroad for treatments are the high medical costs as many

patients do not have proper medical insurance (or any at all) and when in need of surgery, they

cannot afford to pay for it. Surgery abroad can lower the cost to 33%-50% of the price in the USA

for example.

Long waiting lists is another cause people will travel abroad for medical care as they prefer to have

surgery on their own terms, earlier than later. Patients will rather not live in discomfort for extensive

periods of time and rather have the same surgery abroad much faster. A final reason can be that

another country has a better or more advanced medical technology and research in the specific field

of surgery and the patient will prefer to travel to that destination.

1.2 Medical Tourism in IndiaIndia was one of the first countries to recognize the potential of medical tourism and currently it is

the leading destination for global medical tourists. Already in 2004, India has received 150,000

medical tourists and this number has grown by a whopping 33% by 2008 to 200,000 inbound

medical tourists. It is estimated that by the year 2015, India will receive over half a million annual

medical tourists annually.

This is no coincidence, Indias private medical sector offers the most advance medical treatments

and technology available in the world today. Patients can come in and enjoy deluxe accommodations

and be treated by the finest doctors that have western medical training, all for the lowest prices. In

addition to this, patients are not expected to face any language barriers as a most of the population

in India speaks English.


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The government in the country is supporting this industry as well, assisting hospitals in acquiring the

JCI accreditations and awarding funds for renovations and add-ons, everything they can do to

improve both the private and public medical sectors in the country. And if all this isnt enough, afterreceiving medical treatment and recovering, patients are free to keep traveling and enjoy a vacation

in India and the countries surrounding it as India is located in the heart of East Asia.


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2. MEDICAL TOURISM SERVICES IN INDIAA patient can travel to India for just about any medical procedure he or she needs to have done. The

most common major surgeries patients fly in for is open heart surgery and orthopedic joint

replacement surgery as these are very expensive types of necessary surgery if you do not have proper

medical insurance. Indian hospitals today excel in these kinds of treatments and there are many

hospitals specialize in both medicine fields.

Cosmetic procedures are also a very popular type of procedure to have done in India since medical

insurance does not usually cover this kind of operation and the costs can be fairly high. Patients will

travel for any plastic surgery, starting from breast augmentation and enlargements to complete

facelifts and tummy tucks. There are many private hospitals in India as some stand out with world

renowned names. Apollo Hospitals is a main Indian chain that runs 53 different hospitals with over

8,500 beds. Max Healthcare is another known private hospital chain that runs eight medical centersin the national capital region in India.

2.1 Medical tourism is a growing sector in India. Indias medical tourism sector is expected toexperience an annual growth rate of 30%, making it a $200 billion industry by 2015. As medical

treatment costs in the developed world balloon - with the United States leading the way - more and

more Westerners are finding the prospect of international travel for medical care increasingly

appealing. An estimated 150,000 of these travel to India for low-priced healthcare procedures every

year.

Advantages for medical tourists include reduced costs, the availability of latest medical technologiesand a growing compliance on international quality standards, as well as the fact that foreigners are

less likely to face a language barrier in India. The Indian government is taking steps to address

infrastructure issues that hinder the country's growth in medical tourism.

Most estimates claim treatment costs in India start at around a tenth of the price of comparable

treatment in America or Britain. The most popular treatments sought in India by medical tourists are

alternative medicine, bone-marrow transplant, cardiac bypass, eye surgery, and hip replacement.

India is known in particular for heart surgery, hip resurfacing, and other areas of advanced medicine.

2.2 Growing Prospects: India could be hosting 2.4 million medical tourists by 2020, almost four timesthe number it catered to in 2010. And thats not all. The figure is projected to rise to 4.9 milliontourists by 2025, Of the over 600,000-odd medical tourists that visit India today, over half or 55%

hail from two regions Africa and West Asia. The market size of medical value travel would cross Rs.

620 billion by 2020 and Rs. 2,000 billion by 2025 from Rs. 45 billion in 2010, which forecasts a 30%

annual growth for the industry for the next 15 years.

In the National Capital Region (NCR) alone, the three largest hospital chains, Apollo Hospitals,

Fortis Healthcare, and Max Healthcare attended to 15,500 foreign patients in 2010. Of this, a quarter

or more of the tourists who visited fortis and Max came from West Asia while Apollo derived one-

fifth of the traffic from this region. Africa accounts for 32% of Maxs medical tourists, 15% of


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Fortis and a fifth of Apollos share of medical tourists. Neighboring Saarc countries account for

40% of Fortis, 25% of Apollos and 18% of Maxs traffic of medical tourists. The United States,

Europe and other countries accounts for only one fifth of the total patient pool for all the threehospital groups.

Acknowledging Asia as the biggest gainer of global medical value travel, Analysts identify two large

drivers that could spur the projected growth. The presence and expansion of multiple well-

established corporate organizations (hospital groups), and India's unique position to embrace

Ayurveda and alternative medicine as it adopts a more holistic approach towards healthcare delivery

could attract more wellness tourists, different from those who come here for core surgeries mainly

in the areas of cardiac or other general procedures.

A rate chart comparing costs of different procedures could make it clear as to why India could utilise

its edge in weaning away a large share of tourists from other destinations. A coronary artery bypassgraft that could cost $70,000-133,000 in the US and between $16,000 -22,000 in other medical

tourism hotspots like Thailand and Singapore, costs about $7,000 in India, according to Indian

Medical Value Travel Association.

A bypass surgery with heart valve replacement that costs $75,000-140,000 in the US and between

$22000-25000 in Thailand and Singapore is done in India at $9,500. Similarly, a hip or knee

replacement that can set you back in the US by $30,000 to $55,000 and can cost between $9000 to

$12,700 in Thailand and Singapore would only cost $7200 in India. Even cosmetic surgeries, such as

a facelift, for which customers have to shell out anywhere between $10,000 to $16,000 in the US,

$7500 in Singapore and $5000 in Thailand, costs just $4800 in India.

Even then compared to the Southeast Asian countries, India has not been a runaway success in

medical tourism yet. Head of a corporate hospital explains that value is just one variable a medical

tourist considers while firming up a decision. The entire infrastructure in these (Southeast Asian)

economies is customised to give a pleasant experience to the medical tourist, from the point he lands

till he leaves. They have also been marketed for very long as medical and wellness tourism

destinations. That is not the case in India, where hospitals are operating as 'islands of excellence' and

the supporting infrastructure around it is often poor, Also India hopped into the race to lure in

medical tourists very late and the segment is still picking up.

healthcare telemedicine and medical tourism in india

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