Chapter 2: LITERATURE REVIEW
2.1 Medical tourism
2.1.1 Introduction to Medical tourism
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 traveling to and staying in place outside their usual environment for leisure, business and other purposes.’ Understanding of word medical and tourism individually is not sufficient to define Medical Tourism. Medical Tourism is combination of various and definite activities and clear understanding of such activities is essential. (Dr Prem, medical tourism)
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 ‘The Medical Tourism is the 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.’ Medical travel refers to the international phenomenon of individuals traveling, often great distances, to access health care services that are otherwise not available due to high costs, long waiting lists or limited health care capacity in the country of origin. (UNESCAP, 2007)
Five key driving the increased popularity of medical tourism:
Technological improvements drive medical tourism, like more efficient global transportation and communication systems. The flattening of the world through the Internet and technology in medical industry are improving the quality of services.
Patient access to health information on the Internet has increased knowledge and choices. Electronic communications and exchange of health information are faster and easier.
When patients don’t have health insurance or their health insurance does not pay for all the care they need, the cost of the care is shifted to those patients with health insurance. This is known as Cost Shifting. The competition in industry is not operating on the proper objectives. The focus should be on providing care to patients, not to gain economy of other countries or build the tourism sector from needy to sick patients. Moreover, the cost of medical treatment in developed countries is extremely high. Hence, private, social and corporate health schemes are very costly. The above pay model is shifting to individuals. Therefore, Cost is another driving factor.
The emergence of the new consumer needs, like avoiding waiting queues to get medical treatment or the possibility to have the latest medical treatment, requires new solutions which are not available in consumer’s home country. So, Need is another driving factor.
Hospitals are adopting the more luxury hotel concept rather than a traditional unexciting general wards. After the surgical procedure, there is the opportunity to engage in attractive tourism, which is certainly a better change for patient. For example, a patient may take a safari trip in South Africa after an orthopedic surgery, a Taj Mahal trip after eye surgery in India, and a Mayan cultural experience after cosmetic surgery in Mexico. Hence, Change is another key factor.
Demographic drivers such as an aging population due to baby boomers causing significant strain on national healthcare system are a driving factor.
2.1.2 Why choose India?
Medical tourism or health tourism is on a rise in India. It is starting to be considered as one of the most attractive locations for medical tourism. As per a research report ‘Booming Medical Tourism in India’ India’s medical tourism industry is going to grow by 27% in the time period 2009-2012. In 2007 alone, India received 450,000 medical tourists and is expected to receive close to 1.1 million medical tourists in 2012. Currently India has 16 JCI Accredited Hospitals across the country.
Some of the most sought after procedures by medical tourists in India are alternative medicine, bone-marrow transplant, cardiac bypass surgery, eye surgery, orthopedic surgery, In Vitro Fertilization (IVF) or Infertility Treatment and dental procedures (such as dental implants, veneers etc.) commonly known an Dental tourism. Cosmetic surgery or cosmetic procedures and dental tourism are on a rise in India as well.
So what are the reasons to choose India as your medical tourism destination?
No. of Foreigners treated in (2002)
Cosmetic surgery, organ transplant, dental treatments, Joint Replacement
Organ Transplants, Fertility treatments, cardiac care
Middle East, UK, USA
Cardiac care, Joint replacement
USA, Develop countries
Cosmetic Surgery, Dental Treatment
First and foremost is the cost factor. The cost savings are immense. As per the report by ‘Booming Medical Tourism in India’, medical tourist can save up to 60%-95% on their treatment cost by getting their treatment done in India.
The second most important factor according to me is the technology and international standards. Top Hospitals and healthcare facilities in India have the latest equipment and technology, which is at par with the medical facilities in the developed world. With the rise in medical tourism, more and more hospitals are investing in the latest equipments and getting internationally recognized certifications, such as JCI. As per Deloitte report, India has 10 JCI certified hospitals in 2007, and in 3 years India has added 6 more to the list.
The doctors in India have the expertise, which again is at par with the doctors in the developed countries. Today Indian doctors in every field are recognized in the world community for their work and contributions. Most of the doctors working in the big name hospitals have degrees and certifications from US and Europe.
Medical tourist get priority treatment in Indian hospitals as opposed to waiting for weeks or even months in their own country. This is a huge advantage as patients wanting to undergo say a hip or a knee replacement will have to bare the pain till they are not scheduled for treatment, which sometimes can take up to 3 months.
No language barrier. As English is one of the most used languages in India, medical tourists don’t feel lost in this country. Also, if you are from a non-English speaking country, translators are provided to make your stay as comfortable as possible.
Due to its beautiful culture, history and increased reorganization and popularization of yoga, Ayurveda and meditation more and more people are flocking to India for mental and physical peace.
Andhra Pradesh is one of the most prominent state in India for medical tourism as many of the big name medical centers have opened their facilities in this city. Other cities like Mumbai, Delhi, Bangalore, Ahmedabad are quickly catching up to attract international patients.
Andhra Pradesh is considered to be the 5th largest state in India and the largest State in South India. It has a population of 76, 210, 007 and a literacy rate of 45.11% (Andhra Pradesh tourism, 2010). It has become a major IT hub. However its growth with respect to the medical tourism is very slow. Andhra Pradesh is very popular for many non-invasive therapies like Yoga and Ayurveda. Apart from these tow alternative therapy, naturopathy, traditional healing systems also play major role in developing medical tourism in the state. Recently it is competing with other states as some world class hospitals are established in the state. Some of the examples for these are Apollo hospitals, L V Prasad eye hospital, Nizamia general Hospital etc (India line, 2010). It is stressed that the medical tourism is not achieving prospects in Andhra Pradesh when compared to departments, IT and biotechnology. The failure in the medical tourism in Andhra Pradesh is attributed to the lack of synergy between the health and tourist department. It is further noticed that, the number of foreign patients coming to Andhra Pradesh is just not even 1% to that of Bangkok (Hindu, 2010). It is clearly stated by many hospitals’ directors that the Government has to take necessary strategic approach in order to improve medical tourism in Andhra Pradesh.
Apollo, Wockhardt, Fortis Healthcare, Max India, The Global Hospitals Group, MIOT Hospitals and some of the prominent hospitals catering to medical tourists. Apart from this, there are a large number of small clinics such as eye clinics, dental clinics, hair loss clinics, IVF clinics, message and spa clinics that exist across the country that are catering to medical tourist who are interested in elective surgery. (Nikhil Lamba, ClinicsOfWorld)
2.3 Collaboration and Partnership
Medical tourism operators can be divided into two groups. First, there are medical centers such as hospitals and clinics. Medical centers that actively attract international patients are not involved only in the medical procedure itself, but are, in many cases, also responsible for all patient logistics from arrival to departure. Often the hospitals involvement already starts before arrival with the processing of the visa requirements and only ends after departure with patient follow up.
The second group consists of medical tourism facilitators who function like agents and associated service providers. These are often smaller companies with just a few people on their payroll and most of them have spread their risk by dealing with hospitals and clinics in a number of different countries. Those medical tourist agents which are dealing exclusively with hospitals of only one country or region are exposed to the same risks as the hospitals with whom they work.
These facilitators offer global health care options that will enable international patients, primarily from the United States of America and Europe, to access world health care at a fraction of the cost of domestic care. By selling a type of medical value travel, they focus particularly on the self-insured patient. Some companies charge clients a flat rate commission or a percentage of the total cost of care. Others do not directly charge customers, but are paid by the hospitals to which their clients travel for care.
Health care travel packages can include all costs associated with medical care, air and ground transportation, hotel accommodation, use of a cell phone in the destination country, practical assistance from a local company representative at the health care facility, travel arrangements for a companion, stays in nearby resorts during the post-operative recovery period and side trips to tourist destinations.
2.4 Promotional Strategies
Corporate hospitals in Andhra Pradesh brought in five-star facilities and hi-tech medicine. Both the state administration and the corporate sector see the benefits of synergy for profits and have hence evolved separate as well as combined promotional strategies (Qadeer 2009; Gupta 2006). The state is proposing Medical Tourism in its own institutions. It invests directly in infrastructure and tourism to push its policy support to the corporate sector in earning foreign exchange by treating Medical Tourism as a trade. This encourages all the players directly or indirectly involved in Medical Tourism to invest and expand their businesses â€“ corporate hospitals, the aviation industry, private tour services, travel operators, the hotel and hospitality industries (Qadeer 2009; Gupta 2006).
The state has several interests behind its promotional strategies for Medical Tourism. One is ‘medical diplomacy’ to strengthen international relationships and friendships with neighbouring countries. Behind this seeming altruism lies the motive of enhancing economic growth, by not only commodifying medical care and supporting the private medical industry but also promoting investments in sectors supportive of MT. These include the Indian Healthcare Federation, private and public insurers, policy institutions, and the industry players mentioned above (CII-McKinsey 2002).
Tie-ups within the hospitals, hotels and tour operators are being promoted and are on the rise (CII-McKinsey 2002). Hyderabad, capital city of Andhra Pradesh has opened international airports and now offer direct flights from abroad to ease travel for patients. Yashoda hospital in Hyderabad has an airport kiosk and is planning a helipad on the terrace to airlift their patients (Shaffi et al 2007).
Asia has become a prominent destination for global medical tourists. Within it, India has a relative advantage, and Andhra Pradesh is evident from the institutions involved and the services offered as well as the low cost of treatment (Qadeer 2009; Gupta 2006). Its so-called ‘win-win situation’ however, is based on the assumption that services for the haves and have-nots are totally independent of each other and the disconnect is rational. It is this very assumption that is flawed. In its effort to fill its coffers through MT, the government has underplayed the obvious contradiction between a vast uncared â€“ for majority and an unethical focus on profits through MT (Shaffi et al 2007). It has ignored many of the underlying negative implications of MT such as shift of subsidies to the private sector and extremely low inputs in public sector healthcare (Roy Choudhury and Dutta 2004).
India has 16% of the world’s population, 18% of the world’s mortality and 20% of the world’s morbidity and our public expenditure on health is still 1% of gross domestic product (GDP). Budget 2010 is no different from the previous years (Bali 2010) (Qadeer 2009; Gupta 2006).
Added to this is the incoming evidence of inequity and rising costs of medical care. The huge gap permitted between thesalary scales of public and private professionals has encouraged the movement of personnel from the former to the latter. This is particularly true of the shortage of nurses in the public sector, who are leaving for private and overseas jobs (Shaffi et al 2007).
Attracted by the higher scales and an open system of consultancy, experienced specialists too are moving away from public sector. While experienced doctors in the public sector are allowed to work in private institutions that benefit from their experience and fame, the government has no innovative policy to retain competent professionals or to regulate salaries and employment conditions across sectors (Qadeer 2009; Gupta 2006).
Marginalising the concept of comprehensive primary healthcare by limiting primary-level care to at best First Referral Units (FRUs) and district hospitals denies tertiary care to the less-privileged unless they are ready to sell off their assets. This is reflected in the burden of debt due to illness treatment, which has increased to 40% of the total debt as per the 52nd round National Sample Survey (2000).
Another critical dimension of this growing industry is the probable impact it has on the countries it serves. Already there are concerns expressed in the US. Asian MT is seen differently by different stakeholders. The insurance companies and medical
Organizations see its ‘outsourcing potential’ for lowering their own costs and enhancing profits. The uninsured and those who cannot afford their own private services see it as an opportunity. The state sees it as a mechanism for savings and as a price control mechanism in its medical market (Qadeer 2009; Gupta 2006).