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The medical
community has always been blamed as being hopelessly disconnected from the
ailing masses, be it financially or geographically. When one falls sick, the
arduous and tedious task of finding a suitable practitioner begins. The
appointments, arrangements and accommodation take up more time than the actual
medical/surgical procedures themselves. If one is so unfortunate as to be in
an unfamiliar non-native environment, as in the case of expatriate patients,
the story can take unforeseen dimensions including malpractice allegations
mainly because of communication barriers as well as other factors.1
India was
one of the first developing countries to suffer a drain of health workers and
was the largest source country for doctors in the 1970s, many of whom have
stayed on in the United Kingdom, Canada and the United States.2 Ironically
the trend has reversed to some extent over the last decade with the increase
in "medical tourism" in which patients from developed countries seek to
undergo medical procedures in India at reduced cost rather than the other way
around. Medical tourism may be broadly defined as patients opting to go to a
different country for either urgent or elective medical procedures. Foreigners
in increasing numbers are now coming to India for private health care.3 They
come from the Middle East, Africa, Pakistan, and Bangladesh, for complex
paediatric cardiac surgery or liver transplants—procedures that are not done
in their home countries.
They
also come from the United Kingdom, Europe, and North America for quick,
efficient, and cheap coronary bypasses or orthopaedic procedures. The common
packages offered are cardio-thoracic, neurologic, gastro-intestinal,
orthopaedic, renal, ENT, ophthalmology, dental, cosmetic and tumour surgeries.4 For
example, a 44 year old woman from Norwich had two options after having endured
intractable pain caused by osteoarthritis of the hip for two years - wait for
her turn in the NHS or seek treatment in a private hospital. She took a 10
hour flight to India and checked into a corporate hospital at Chennai. After a
Birmingham hip resurfacing procedure on her, the hospital arranged a visit to
a traditional Indian herbal medicine centreas well.5 This
is similar in concept to the Aesculapius museum in Epidaurus where ancient
Greeks used to travel to seek blessings of the God of healing! All this has not gone uncriticized, though. Though the corporate hospitals are creating
medical tourism as a new economic entity that gets major policy attention in
the National Health Policy 2002, a majority of patients in India are left in
the hands of the market forces. It is claimed that medical expenditure is the
second highest cause of rural indebtedness in India.6 However
the proponents opine that the fear of creating a two tier medical service is
unfounded, as this already exists in India. It is hypothesized that this could
be tackled by using the revenue generated by medical tourism toward improving
the provision of health care available for the people in India. This would
then strike a balance that would be beneficial to all.7 India,
however, is pitted against Thailand, Singapore and some other Asian countries,
which have good hospitals, salubrious climate and tourist destinations. The
sub-continent's medical hubs - Mumbai, Bangalore, Pune and Goa - not to leave
small cities like Mangalore - might become destinations where “one can combine
a tummy tuck with a trip to Taj Mahal” or “a cataract surgery with a trip to
Kanya Kumari”. A study was undertaken by us to assess the knowledge, attitude
and experiences of the population of a suitable cross-section regarding the
emerging scenario of Medical Tourism with special interest specifically to the
state of Karnataka and Mangalore in particular.
To assess knowledge, attitude and experience of medical tourism among the Karnataka, non-Karnataka and Non Resident Indian population.
A cross-sectional study was conducted to assess knowledge, attitude and experience about medical tourism among a cross-section of families from Karnataka (Kannadigas), outside Karnataka (Non-Kannadigas) and Non-Resident Indian (NRI) population. Personal Interviews were conducted with acquaintances in residential apartments and a survey was conducted among the professional college students of Non-Karnataka quota regarding their families using a pre-structured questionnaire. Non-resident Indian families were covered as belonging to those with their wards who got admitted to the professional college under NRI quota. Questions were asked on whether they were satisfied with the health care facilities in their own country/place of stay; whether they have medical insurance; whether they have undergone any previous Medical/Surgical treatment for any major ailment; whether they have heard of health tourism packages in India; how they came to know about health tourism; Was it through doctors, friends, internet or other sources (TV, Print media etc); Whether they have come to India as part of a health tourism package; if yes or if they were planning to come for treatment to India, what would be the driving factor(s) - would it be the cost, quality of medical care, attractive health package, good doctor-patient interaction, easy obtainment of visa or because it is their native place ? If they had taken up a medical tourism package, they were quizzed about how they found the whole experience. They were also asked about the facilities provided to them, as a part of the health package, such as, hotel accommodation, transport, flight booking, sight seeing, translator, locker facilities, other travel arrangements, country specific cuisine and airport pick up. Overall 140 individuals were interviewed. For completeness of the coverage of the topic, 15 e-mails were sent to elicit the views on the issue from a sample of foreign nationals as far away in Johannesburg, Ankara etc. for their experience in other countries as part of the health tourism package. The data was tabulated and percentages were worked out.
Of the surveyed, 38 were from Karnataka (Kannadigas), 57 were Non-Karnataka (else where from India) and 45 were Non-Resident Indians (NRIs). The following were the major findings. Knowledge 107 (69%) of the sample (including Foreigners) surveyed was aware of specifics of medical tourism, out of which 28 (26.3%) are from Karnataka and 37 (34.6%) from the non-Karnataka population and 17 (15.9%) are Non Resident Indians and the source of their knowledge is given in Table 1. One can appreciate the role of information superhighway (Internet) in converting this superficial knowledge into action especially with regard to NRIs as seen in further analysis.
There are two aspects to medical tourism. One is that there are world class facilities in a certain place, however, the cost or waiting period makes it formidable for the consumer forcing them to look for better, easier and cheaper options. The second is that there are areas were world class facilities are lacking and they have to look out for places where affordable care is available. In the study we have added an e-mail survey from such locations where the satisfaction with local medical facilities is very poor, although the number of respondents is low (Table 2). Medical insurance is another facet of the story. Even among NRIs who have more insurance cover than the localites there is a good number who will have to come back home for many of the medical treatments which are formidably costly back at where they work or stay. The apparent satisfaction of locals with the medical care available locally would appear paradoxic in that there are always complaints such as medical negligence perceived or otherwise, not infrequently, in the lay press.
Among the NRIs there is always a greater need for procedures and surgeries compared with localites who always take easier routes to avoiding necessary care. The evasiveness which is exhibited by the localites is opposite to the pro-active attitude of the NRIs of getting things done effectively and on time. Another reason they do it is because they cannot always come back for it when there is an emergency. Attitude Driving factors for opting for a medical tourism were offered by the study group as follows: A – Faster treatment with less delay – 45% B – Attractive health package – 22% C – Recuperation facilities – 19% D – Efficacious handling of appointments – 14% Among NRIs, majority desired assistance with flight bookings, hotel accommodation etc. Experience It is noted that only 7 people among the interviewees have undertaken a medical tourism package in the past of which 5 of them were NRIs. e-mail survey Fifteen e-mails were received with replies from foreigners from as far away as South Africa and Ankara. All have heard of medical tourism. All have expressed their satisfaction with the concept of medical tourism. Most of them are dissatisfied with health care facilities in their own native countries. Out of these, five foreigners have opted for a medical tourism package, but none in India. Three have undergone surgeries for heart care, one has taken an orthopaedic package and one has undergone cancer related treatment. One South African citizen has visited Thailand for a health package and has described the experience as “EXCELLENT”. None of them have come to India. All agree that the quality of medical care and cost would be the driving factor for their opting for the medical tourism in India.
“First world treatment at third world prices” is the motto offered by the medical tourism industry. A study by the Confederation of Indian Industry forecast that medical tourism will reach $2.3 billion dollars a year by 2012 and could further rise significantly. In 2004, India treated and cared for 1.8 lakh foreign patients. From the point of view of outsourcing potential, there are statements emanating from the developed world such as "Companies like General Motors spend $6 billion a year on health care and it is killing them. These firms are going to have to turn to India”. However, the major problem in recommending India as a target destination would be the lack of support by insurance companies. At the same time, it is also an advantage that the uninsured would flock to India for the very same reason from the non-organised section of population of the western world. India offers world-class healthcare that costs substantially less than those in developed countries, using the same technology delivered by competent specialists attaining similar success rates. India's main USP is the prospect of low-cost treatment by highly professional medicos. Many say that it is not just the cost but competency that is India's selling point. The death rate for coronary bypass patients at one of the leading centres is 0.8% and the infection rate is 0.3%. This is well below the first-world averages of 1.2% for the death rate and 1% for infections. India offers not just treatment but spiritual and mental healing as well. A number of private hospitals offer packages designed to attract wealthy foreign patients, with airport-to-hospital bed car service, in-room internet access and private chefs. Emphasizing the positioning of Karnataka state as a destination, there are an estimated 7,000 to 8,000 of health tourists to the state per year. Bangalore is home to high tech modern tertiary care hospitals with high-grade facilities in cardiology, orthopaedics, neurosurgery and oncology to give a few examples: Wockhardt Hospital receives patients from UK and USA for heart surgeries and angioplasties, Narayana Hrudyalaya's paediatric heart surgeries on babies from neighbouring countries have been well-publicised, Manipal Hospital draws in NRIs for its services in advanced medical areas etc. Proper synergy between the health and tourism sector is such that one propels the other. The fact that international air travel has become cheaper in recent times has added to the economic advantage for health tourists. One of the upcoming hospitals in the small city of Mangalore draws a lot of the NRIs with origins in the Gulf region.
Medical tourism is becoming one of the major aspects of hospital administration whereby the English speaking staff can cater to foreigners or non-resident Indians or even within the country to those people in other states as well. This brings in the much needed revenue to run corporatised hospitals at a much better fashion and at the same time gives the choice for subsidising the cost of care for needy local patients. More and more expatriates are waking up to the economic advantage of this possibility even with the provision of medical insurance schemes. So also, the world is realizing the potential of uninsured citizens of the developed world and richer citizens of under-developed world to avail word class surgical and procedural skills from countries like India. There is competition increasing from other corners of the world from India’s point of view (Appendix 1). This is the right time to have a policy for balancing the two-tier system of health care argument – one for the poor and one for the rich – and utilize the globalization movement to our advantage by putting more into tourism and making first class medical care a reality for all.
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