The success of doctors of Indian origin in the West is also believed to have boosted the credibility of and the confidence in the Indian healthcare industry
There could be justifiable reasons to question the rationale of categorising international patients, coming to India to avail our healthcare services, as tourists. [It just sounds... frivolous!] Without getting into a debate over the terminology, here’s The Dollar Business’ diagnosis as to why India is fast becoming one of the most sought-after destinations for international patients
Satyapal Menon | @TheDollarBiz
This preference for India has opened the floodgates of not just healthcare providers, but also spawned a service industry with a gamut of players involving tour operators, facilitators, agents, hospitals, online portals and, of course, doctors, raking in the greenbacks from the spin-off accrued through foreign tourist arrivals in India for medical treatment. Strangely, though the so-called medical tourism or medical value travel is being bandied about as a significant contributor to foreign exchange earnings – however unethical it may sound – the picture related to who exactly constitutes a medical tourist is quite hazy and confusing. Questions arise as to whether a person who visits the host country for purposes other than treatment, but during the course of his visit falls ill and is hospitalised or gets treated in a hospital, be categorised as a medical tourist? Do foreigners who visit a country for leisure and pleasure, and also have hospital treatment in their itinerary, be considered as medical tourists? There are also the genuinely ailing, who go to a certain country specifically for the purpose of treatment, but also make use of the opportunity to spend some time, especially while convalescing after treatment, in sightseeing and other leisure activities.
From East and West
The only semblance of clarity that could be had on the classification is from foreign arrival records at various Indian embassies, which require tourists to state the purpose of their visits. While it was only the neighbouring countries from where the flow of medical tourists started, and the reason was lack of specialised healthcare facilities, later, NRIs from US, UK, and other developed nations, were making a beeline to corporate hospitals in India for treatment. The reason was simple – extremely low cost of healthcare services compared to that in their countries of residence. Over the years, high confidence levels in the quality and efficacy of healthcare services in India has been instrumental in boosting the number of international patients coming to the country.
If it was domestic demand and the pathetic state of government hospitals that led to the mushrooming of corporate hospitals in India, it was the burgeoning number of highly discerning patients in India and from abroad that has led to the setting up of hundreds of multi-specialty and super-specialty hospitals, all over the country.
Health and wealth
With an eye on garnering the growing inflow of foreign tourists for medical treatment, corporate hospitals are, today, offering comprehensive packages to facilitate a smooth passage to India and a comfortable stay during and after treatment. “Apart from airport pickups and drops, we also provide patients food based on his or her particular religion. We also provide tourism facilities if international patients want to have a look at Mumbai and nearby areas. Apart from this, we have a round-the-clock special cell, dedicated for international patients, to serve their requirements,” Dr. V. Malathi, International Medical Coordinator, Seven Hills Hospital, told The Dollar Business. International patients also have the advantage of choosing a hospital according to its infrastructure and other credentials. “Today, almost all leading hospitals in India are involved in online marketing of their facilities, pricing and packages, which makes it very easy for international patient to study and do his/her own research before approaching any hospital,” Dr. Malathi added.
Although projections can prove to be dicey since medical tourism is yet to be brought under a clearly defined segment and there is also a lack of specific data on whether tourists seeking wellness and alternative medicine treatment come under this category, industry sources claim the current size of the medical tourism industry in India is about $3 billion, with per year tourist arrivals of 230,000 in FY2014 (as per Punjab Haryana Delhi Chamber of Commerce and Industry). Industry insiders also claim the industry is expected to reach $6 billion by 2018, with the number of people arriving in the country for medical treatment set to double over the next four years. At the same time, according to a KPMG-FICCI analysis, the global medical tourism industry is expected to grow at a CAGR of 17.9% between 2013 and 2019 to reach $32.5 billion. The increasing numbers of ageing and uninsured population worldwide is struggling against the challenges of cost, quality and access to healthcare, the report stated and adds that in developed countries medical tourism often provides an alternate way for uninsured or underinsured patients to obtain economical treatment.
Arterial spread
Today, India is positioned 2nd in the world in foreign tourist arrivals for medical treatment, with Thailand occupying the top position. Malaysia, South Africa, Singapore, Cuba, Argentina, Australia and Mexico have also emerged as major destinations for international patients. Though a majority of the patients coming to India for treatment are from the Middle East, Africa, Bangladesh, Afghanistan, Maldives, Pakistan, Bhutan and Sri Lanka, the country is also increasingly becoming the favoured destination for medical tourists from Europe and US. India is preferred by international patients, primarily, for its expertise in cardiac and orthopedic procedures, in addition to other specialised areas like neuro-surgeries, cancer treatment and organ transplantation. An ASSOCHAM study on the subject points out that top-notch healthcare facilities like cardiology, joint replacement, orthopedic surgery, transplants and urology, available at a substantially lower price, are certain key factors making India a favoured location for medical tourists.
One of its kind
From a pricing point of view, major medical procedures in India are way below than that in not only the US and Britain, but also 40-70% cheaper than that compared to its the nearest competitor – Thailand. The KPMG-FICCI study claims that while a heart bypass surgery in US costs about $1,30,000 and about $18,500 in Thailand, it can be done in India for just $7,000. Similarly, while a heart valve replacement can set you back by $1,60,000 in US and about $9,500 in Thailand, you can get it done for just $9,000 in India. The same is the case even when it comes to orthopedic operations like a knee replacement, where India is at least 30% cheaper than Thailand and at least 90% cheaper than US. “It is both the pricing and quality of our healthcare services that is attracting international patients to India. Our hospital specialises in cancer treatment and on an average we treat 500 international patients per year. Most of the patients are from Bangladesh, Pakistan and Nepal” S. H. Jafri, Senior Public Relations Officer at Mumbai based Tata Memorial Hospital, told The Dollar Business.
Ironically, like any other kind of export, devaluation of the rupee has added value and is proving to be a boon for Indian hospitals. Attributing the trend of increasing number of arrivals for medical treatment in India to this factor, S. Rawat, Secretary General, ASSOCHAM, in a report published by the industry body, said, “A medical procedure that would have cost $10,000 in 2012 is now priced $7,000.” Significantly, even after including the cost of traveling from their home countries, staying in a luxury hotel and other incidentals throughout the period of treatment and recuperation – say one month – the cumulative expense for an international patient works out to only a little over half of that of the total value of the medical procedure in US!
A billion hands
A survey conducted by US-based Medical Tourism Association (MTA) reveals that nearly 80% of the demand for medical travel is driven by cost savings. The survey claims that American medical tourists spend between $7,475 and $15,833 per medical travel trip. Among those surveyed, the cost of medical treatment (85%) and state-of-the-art technology (83%) were the most important factors in their decision to travel abroad for treatment. However, all this focus on the cost factor may take the sheen out of the actual quality and capability of Indian hospitals in terms of infrastructure, expertise and technical manpower. Critics point out that for an ailing person, though affordability is a priority, low cost and ineffective treatment is definitely not. So, how are the hospitals managing to provide healthcare at such low costs, which by all means could be the cheapest as compared to most developed and even some developing countries? One industry source revealed that the answer lies in India’s cheap human resources.
Of course, it is not always that the best quality is available at the lowest price. The growing demand for cheap options and alternatives have also triggered the proliferation of sub-standard hospitals in India, all vying for a share of the pie. Narrating an instance, Daljit Singh, President, Fortis Healthcare, told The Dollar Business, “A Nigerian lady, who was referred to me by a friend, had two kidney transplants done in India, both of which ended in failures. After enquiring about the hospital in which she had undergone the transplants, I found out they were done by a doctor and a hospital with doubtful credentials. She also wanted to know if she could have a kidney transplant for a third time. So, I put her in touch with our doctors and they interacted for over a month. Later, she got the transplant done successfully in our hospital. There is a lacuna in India in terms of ethical and regulated treatment.”
The Yankee angle
Interestingly, US, despite not being a significant source of medical tourists to India – apart of course from NRIs – has often been indicating a propensity to view the healthcare segment in the country with more than a growing interest for some years now. The focal point of interest from the US perspective is the cost differential and India’s inherent potential based on this factor to attract American medical tourists in greater numbers. The US concerns about India’s growing popularity, as a destination for medical tourists, could not have been more evident when the popular American TV host Glen Beck, in one of his shows, had some years back, rather grudgingly admitted – with a few unsavoury comments about pervasive squalor and unhygienic conditions – that the corporate hospitals in India were capable enough to render quality healthcare. He did add in his usual inimitable sarcastic style though – perhaps with the intention of not taking credit away from US – that most of the doctors in their (American) hospitals were ‘Harvard educated’.
From India’s point of view, the prospects, like always, though yet to materialise in terms of considerable numbers, looks quite promising, particularly since apart from the high cost of healthcare, there are also reportedly other problems like lack of proper accessibility for affordable medical treatment in the West. Actually, when compared to even the American system, India, with its well-developed network of hospitals and facilitators, has a much higher capability to ensure speedy and hassle-free access to medicare for patients. Indian corporate hospitals have also demonstrated a high success rate in complex cardiac procedures and also in the areas of neurosurgery, nephrology and ophthalmology.
Just one thing more
But before one gets carried away by the potential and performance of India’s healthcare sector, there are certain grey areas that need to be remedied to instill confidence among patients in developed nations, where people are highly conscious and aware of their rights. In the developed world, there are appropriate legal processes, which deal with alacrity, any medical complaints about botched surgeries and treatment. Referring to one of the factors attributed to the low cost of healthcare in India, Daljit Singh said, “We are not a very legally oriented society. India’s medico-legal costs are extremely low. In America, if any problem occurs, you are taken to the court. The cover for such medico-legal costs is very expensive over there.” However, in India, there is no effective legal palliative for medical mistakes committed during treatment. India’s legal machinery, equipped with tortuous and archaic laws and notorious for its laborious and laggard functioning, could take ages to redress medico-legal complaints, which could be demoralising and discouraging for international patients.
The panacea is in rectifying this systemic disorder and putting in place a system that provides for fast-paced remedies to the aggrieved and also mandating transparency and accountability of healthcare service providers.
Testimonial
I have come all the way from Afghanistan to Delhi to treat my brother, who is suffering from paralysis. We have come to India since Afghanistan lacks modern infrastructure and equipment. Although most Afghan doctors are as well trained as those in India and cost of treatment is also equivalent, accessing modern facilities in Afghanistan is a very costly affair. Even if one is ready to shell out the money, the quality of treatment won’t be as good as in India, because Indian hospital staff are extremely disciplined and take proper care of the patient. At times, in our country, we have to remind the nurse to give medicine to the patient, but here the nurses do it by themselves.
The only difficulty for me in India is the language. I cannot speak English (the interaction was done through a translator) and can barely speak any Hindi. So, we are forced to hire translators, who are very expensive and there’s always a chance of them cheating us. If hospitals, here, could arrange an in-house translator, at a reasonable cost, there would be nothing like it.
I would not even think twice before recommending Indian hospitals to friends and family back in Afghanistan as a trip to India is worth it if you want your family member to get well soon.
“Apollo has set benchmarks for healthcare providers in India and neighbouring countries” - Shobana Kamineni, Vice Chairperson, Apollo Hospitals
TDB: Most reports about India’s growing popularity as a destination for medical tourists, focus on the pricing factor, rather than the specialty facilities and expertise. Do you think it is only pricing that is attracting medical tourists to India?
Shobana Kamineni (SK): I would disagree with this as I believe we have moved from this perception almost a decade back. Today, with hospital groups like Apollo giving paramount importance to quality of healthcare delivery with JCI-Intl accreditations and re-accreditations becoming a regular protocol, such perception of ‘cheap healthcare’ has far moved away and it is more about affordable prices. There is also a huge trust factor with the international insurance segments starting more official referrals, which is only because of our clinical excellence & quality and not cost.
TDB: What is the USP of healthcare service providers in India that makes the country one of the most preferred destinations?
SK: For Apollo, its the 3C approach – Care, Clinical Excellence and Affordable Cost.
TDB: Reports indicate that comparable treatment costs in India are 65% to 90% cheaper than that in US. How are hospitals here able to provide healthcare at such a low cost, without compromising on quality?
SK: Well, the primary difference is the exchange rate. In United States, the pricing models are different and the general price index too (like cost of living) has an impact, things like cost of living in a tier I city in India versus a tier II city. The overall pricing system in India and cost of consumables etc., reduces our cost burden. Quality, of course, is the essence and I see that evolving as part of the healthcare delivery system. Further, US also has one of the most advanced healthcare delivery systems and the requirements of investment on research may be adding to the cost.
TDB: Could you elucidate on the factors that has positioned Apollo as one of the most preferred hospitals by international patients.
SK: Apollo pioneered the healthcare revolution in India and we were the first to set benchmarks for healthcare providers here, as well as those in neighbouring countries. Even before cross border medical travel was identified as a business model, Apollo was a destination for patients from India’s neighbouring countries way back in the 1980s. Our focus on getting the best medical manpower – like doctors from UK and US – has reversed the brain drain. The priority on getting the best of technology and our own patient care model, what we proudly call the Tender Loving Care (TLC) approach, have all added to the creation of our strong identity in healthcare.
TDB: On an average, how many foreigners get treated at Apollo in a year? Which are the various specialties that have the maximum number of international patients?
SK: We receive a substantial number of medical travellers (over 1,00,000) and this is across all major medical specialties. The healthcare buying behaviour changes from each territorial segment (say Middle East v/s Africa v/s South East Asia). However, the highest inflow is for orthopaedic and spine surgeries.
TDB: What is your market share in India when it comes to foreign medical tourists? Which countries are the main source of your international patients?
SK: In organised medical travel (that’s modern medicine), from the data available, I can say that we command a lion’s share of medical travel business in India. In terms of volumes, South Asia is the highest, followed by the Middle East and Africa.
TDB: Depending on the nature of the ailment and the treatment required, international patients prefer hospitals that have a good reputation in the required area of specialisation. Is there any specialty at Apollo, which are particularly preferred by international medical tourists?
SK: There are, in fact, many. We have introduced robotics in spine, which is exclusively available only at our health city. We are the world leader in solid organ transplant programmes and probably, have the biggest centre for procedures as demanding as un-related cord blood transplant.
TDB: Is Apollo sufficiently equipped, in terms of both facilities and expertise, to deal with the growing number of international patients?
SK: Yes, we are and we have strategised organic and inorganic expansion plans.
TDB: What is the state of readiness of Apollo and also the process involved, in accommodating and treating emergency cases from abroad?
SK: Our facilities in Chennai, New Delhi and Hyderabad do receive air lifted cases from other countries and we are well equipped to handle such emergencies. However, these are all primarily from this region.
TDB: There are many complaints about cumbersome processes and multi departmental procedures hampering the passage and also post-operative stay of international patients in India. Do you think the criticism is justified?
SK: Well, it used to be the case. But authorities have relaxed it and we see it improving.
TDB: Apart from treatment, what support services does Apollo provide?
SK: Every major location of Apollo has a dedicated international patients service team that handles everything from concierge services, translator support, international insurance processing and even follow-up assistance.
TDB: How do you envision the future of Medical Value Tourism in India?
SK: I see medical value travel to India at a consolidation stage. We still have new territories to add (like CIS region, Far East) though. Today, the healthcare buying behaviour is changing, the disease pattern is changing and India is certainly ready to be the healthcare destination of the world.
“We accept patients only if they and their attendants come on medical visas” - Dr. Velivela Malathi, International Medical coordinator, Seven Hills Hospital
TDB: Depending on the nature of the ailment and the treatment required, international patients prefer hospitals which have a good reputation in the required area of specialisation. Is there any specialty at Seven Hills that international patients prefer in particular?
Dr. Velivela Malathi (VM): We get international patients especially for adult and pediatric cardiac, orthopedic, urology, oncology, neuro and liver related conditions. Seven Hills (in Mumbai) is a state-of-the-art facility, with 1,500 beds, equipped with the latest technology. We provide 24-hour emergency services from all our doctors as they stay within the hospital campus, which is an added advantage. Further, our pricing is one of the most competitive among all the leading hospitals in and around Mumbai.
TDB: Low cost, and not quality, seems to be the top factor that is attracting medical tourists to India. What’s your view on this?
VM: People usually look for better health care facilities and expertise rather than pricing alone. In fact, for a patient who is travelling out of the country and coming for medical treatment, the pricing factor would be the last priority in deciding the location of treatment. India attracts so many medical tourists basically due to high quality infrastructure and medical expertise. In fact, India is presently equivalent to any other developed country in terms of medical facilities. With the advent of corporate chains of hospitals, a lot of technical advancement have happened over the last few years in the Indian medical arena. So, I don’t agree that pricing, and not the quality of health care, is attracting medical tourists
to India.
TDB: According to reports, the cost difference for a procedure in an Indian and an American hospital can be as high as 95%. How is it that Indian hospitals are able to provide healthcare at such a low price?
VM: Certainly, when one compares with highly developed countries like US or UK, then we might look cheap. But that doesn’t mean we are low in infrastructure or compromise on quality. Several Indian doctors are among the best in the world. In fact, many people from India also go to these developed countries for treatment, with the expectation of better quality. I would say it’s a myth that they are offered better treatment there than what we, in India, offer at super specialty hospitals like ours. In developing countries, the cost of consumables is much less as compared to developed countries. Further, the cost of manpower is pretty low in India as compared to US and other developed countries, which lowers the treatment cost to a large extent.
TDB: How many international patients get treated at Seven Hills every month, on an average?
VM: On an average, we get about 30-40 in-patients and around 50 out-patients international patients per month.
TDB: Which countries are the main source of patients for Seven Hills?
VM: During non-tourism seasons, we get patients from the African continent and Middle East, but during tourism seasons, we do get a lot of European patients, apart from many expats and embassies patients too.
TDB: Since you are dealing with the sick and ailing, how do you ensure hassle-free delivery of services?
VM: Nowadays, things are working very smoothly and at a much faster pace, without any complaints from international patients, provided it is a clean medical case. We don’t send invite letters to any international patient, unless we have properly examined his/her medical reports. Moreover, we accept patients only if they, along with their attendants, come with medical visas and medical attendant visas, respectively.
TDB: What’s your view on the future of Medical Tourism in India?
VM: With leading chains of hospitals being set up in non-metros and with good air connectivity, many international patients are directly flying to such non-metros for quality treatment by highly experienced doctors. So, going by the trend, Medical Tourism is not being limited to only metros, but is spreading fast in non-metros as well, which is definitely a good sign.
“Fortis’ strength is in its strict adherence to Standard Operating Procedures” - Daljit Singh, President, Fortis Healthcare
TDB: What is it that makes Fortis Healthcare one of the leading players in the highly competitive hospital segment in India?
Daljit Singh (DS): We have a highly qualified talent pool of doctors, who have expertise comparable to international standards. Our infrastructure is highly contemporary, which means ‘hospitals are designed around the patient’ to make the patient feel more comfortable. We have a competent support staff in nurses and junior doctors. Fortis is equipped with medical technologies, which match the best in the world. Our strength is in our focus on strictly abiding by Standard Operating Procedures (SOPs) and following the standard protocol in diagnosis and treatment. Fortis is both NABH (National Accreditation Board for Hospitals & Healthcare) and JCI (Joint Commission International) certified, which mandates a thousand parameters related to the process and systems of treatment and procedures to be tackled on a daily basis to ensure flawless and error free functioning. Finally, the icing on the cake is the cost of delivery.
TDB: Healthcare costs in India are one of the lowest in the world. Can you explain the reasons behind the big difference between the cost of a procedure in India and that in US?
DS: Despite having world-class doctors, facilities and internationally recognised accreditations, our costs range between 5% and 10% of that in US. Many hospitals in India are performing cardiac surgeries at $5,000-$6,000, which can set you back by $50,000-$100,000 in US. This applies to even other procedures also. There are several reasons for this difference. Our manpower costs are quite low compared to that in US. For example, while our nurses are paid a salary between $200-300 per month, those in US earn between $3,000 and $6,000 per month. Similar ratios exist in payments to doctors and hospital administrators as well. This makes the treatment there really expensive.
TDB: Doesn’t this compromise quality?
DS: No. It is all about productivity. It is about how much quantum of work you do for the rupee or dollar you invest. And investment is in terms of building, infrastructure and salaries. Hospital capacity is measured in terms of the number of beds. The costings in terms of infrastructure is worked using this as one of the parameters. Looking at the equations in the best hospitals in the country, each bed is valued at Rs.1 crore i.e., roughly between $1,50,000 and $1,70,000. In US, the valuation per bed is between $1.5 million and $2 million! So, looking in totality, their costs are extremely high as compared to India. And yet, when it comes to expertise, our doctors are on par with international standards. The other important factor is that the number of patients that are treated in India or the number of surgeries that a surgeon performs in a day or month (on an average) is significantly higher than their counterparts in the developed countries. So, there is no compromises in quality.
TDB: Medical Tourism is becoming a big draw in India. Which are the specialties that are most in demand among international patients?
DS: You know the term medical tourism is a bit too frivolous. It is almost like saying you have come to see the Taj Mahal and on the way you undergo a surgery. This can be applicable to less serious disorders – like going for a health check or visiting a dentist for getting a root canal done or visiting an ophthalmologist for an eye check-up. A significant number of cases, coming to our hospitals, relate to elective surgeries, i.e., surgeries for which you can wait and those which are not life threatening. People abroad, who need an orthopedic procedure, bear with the problem and finally come to India to get that done. But if you have a chest problem, you know that you cannot rush to India. If a bypass has to be done, it has to be done locally.
TDB: Which countries do you get most of your international patients from?
DS: Most of our international patients are from the Middle East, Africa, Pakistan, Nepal, Bangladesh and CIS countries. We also get patients from US and Europe, but in lesser numbers.
TDB: How do you rate the ease of access, i.e., the expediency with which medical treatment can be accessed in India, specifically in cases that require urgent care?
DS: Ease of access in treating emergency cases is quite low. I would say it is not very good. In India, there is no seamless entry. The problem is that our systems are not integrated. The private and the public sector need to coordinate through several ministries. In emergency cases it is difficult for the patient to go through the process of getting a visa, purchase the ticket and fly down to India. From the aircraft, the patient has to be taken to the hospital by ambulance. In India, ambulances are not permitted to go near the aircraft. Apart from that, patients have to go through security channels. Customs and immigration checks are also required. All this requires vertical integration in a seamless manner, like the case in Thailand.
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