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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
10
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.
19
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
24
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
25
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.