India has immense potential in medical tourism as medical costs skyrocket in the developed countries, the study said. Dr Naresh Trehan, chairman, CII national healthcare committee, said: "In comparison to most developed countries such as the United Kingdom or the United States, treatments like those for dental problems or major procedures like bypass surgery or angioplasty come at a fraction of the costs in India."
The current market for medical tourism in India is small and is mainly limited to patients from the Middle Eastern and South Asian economies. However, it could grow rapidly if the industry re-orients itself to attract foreign patients, the study pointed out. It estimates that the market could grow to about 100 billion $ in the next few years. Joint replacement, cardiac care, cosmetic surgery, ophthalmology and dental procedures coupled with complementary medicine like ayurveda and homeopathy could be India’s ticket to medical outsourcing.

Apollo hospitals have already tapped into the market and attract several patients from the Middle-East and other neighboring countries. Heart care service provider Escorts has doubled its number of overseas patients from 675 in 2000 to around 1,200 in 2003. Almost 10% of Escort’s patients come from Sri Lanka, Bangladesh, Nepal and West Asia.

However if our planners have visions of charter loads of British pensioners hobbling of the plane to get their hips and knees fixed ‘dirt cheap’ in India, then they better think again. The Indian healthcare industry has failed to impress the British government's National Health Service (NHS) to outsource its patients to India. Sources attribute this to Indian hospitals' lacking accreditation from Joint Commission on Accreditation of Healthcare Organisations (JCAHO), lack of standards in terms of quality and rates for healthcare procedures, absence of gradation system and the far from perfect insurance sector here. Experts say that acquiring JCAHO accreditation is a costly and a continuous process, costing around 50,000 to 200,000 USD. It takes around two years to get accredited by JCAHO. The Medical Tourism Council of Maharashtra is trying for it, so if 10 hospitals get together to get accredited, the cost incurred by each hospital would be much less. Hospitals have tried getting rated by CRISIL and ISO but the problem is that such ratings are just not recognized abroad.

Unlike those in the UK, none of the hospitals in India, Goa included are JCAHO-accredited--an imperative to win outsourcing contracts. Also, NHS patients are insured and the total health care expenditure is borne by the government, which does not apply here. Therefore, the NHS is sending its patients to Spain and Germany, which also offer free bed facilities. Also the political imperative would be to out source the NHS patients to member EEC states. With the recent increase in the EEC membership the NHS mangers would be looking at the newer states like Estonia etc to outsource their patients if required.

In stark contrast to the UK healthcare scenario, where hospitals are standardized, audits regularly performed and hospitals graded, the systems are completely absent in Indian hospitals. Top Indian hospitals have high infection and mortality rate, and do not want to share their data regarding these. Concurs Sushil Jiwarajka, chairman, Federation of Indian Chambers of Commerce and Industry (FICCI), “NHS has a long waiting list of patients. Even for a small cataract operation there are patients waiting since two years.
Besides the cost at which healthcare services are offered here, are a fraction of the cost in UK, but our record keeping, software, and systems are not up to the mark.”

If India wishes to get patients from the United States where private players run healthcare, the problems will be much the same. In India, only five per cent Indians are insured and they are corporates. Less than 0.5 per cent individuals are insured. Awareness about healthcare is poor. Rules of reimbursement are stringent, performance of third party administrators (TPAs) are not satisfactory. Discharge details, disease codings, ICD codings and handling of medical records are not in place, making it difficult to get outsourcing contracts from the US.
While the CII-McKinsey study found that there is a tremendous stock of intellectual capital in Indian healthcare and that state-of-the-art treatment/world class surgeries are available in India, the system faces some lacunae. There is a pressing need for qualified specialist nurses and paramedics and qualified hospital administrators. Several private hospitals have invested in nursing education, but are concerned about loyalty: trained nurses often leave India, attracted by the higher wages offered in the Gulf countries. The study says that specialist nurse training will become vital as the number of single-superspeciality and multisuperspeciality hospitals increase.

The study also points out that Indian healthcare is plagued by a lack of standardisation and accreditation, highlighting the need for information management expertise. This nebulous aspect of the market covers a variety of sectors including public health, insurance, hospital management, clinical research and clinical trials. Information Technology, a core competence of the southern and western region, facilitates management of information. There is a considerable scope for partnership in the field of Health Informatics (the application of IT to health data), in the collection of information to established standards in both public and private sectors would be valuable asset in India, says the study.

Goa –A medical Mecca?
Can Goa, which is firmly on the international map as a holiday destination, attract the medical traveler? ‘‘Definitely!” feels Victor Albuquerque owner of Victor Apollo hospital and Victor Exotica and Dona Sylvia resorts who has a number of health tourism projects in the pipeline. He opines that Goa’s famed hospitality industry combined with India’s top hospital group should be able to lure the international patient here. “It needs some time” cautions Dr Digamber Naik MD owner of Vrundhavan Hospital –Goa’s only ISO2001 certified hospital which has been catering to the tourists of the North Goa beach belt for the past decade. He feels that infrastructure needs to be put in place but once that is done Goa will automatically reap from the efforts of the big players in the health industry. With the facilities at the Goa Medical College stretched to breaking point and daily reports of outbreaks of malaria, dengue, hepatitis etc . the man of the street feels that the public health status of Goa has detoriated . One undisputable fact is that the all the key
players US, UK, South Africa etc involved in health tourism have excellent facilities with universal comprehensive health coverage. Even Cuba with its low per capita income has basic health indicators that are comparable to the achievements of welfare systems in Western Europe. Dr Dubashi FRCS, UK based surgeon and Director of Vintage Hospitals UK which provides medical cover for Western tourists -laments about the erratic power supply in the capital city Panaji and agrees that no standards are followed in Goa for either doctors or hospitals. He feels that given the international standards of healthcare Goa would only qualify for backpacker tourism.

The reference to five star hospitals would appear extravagant to a lot of Goans who have to put up with dirty and crowded OPD’s, overworked doctors and depleted hospital drugs store. But the fact is that hospitals in the west are increasingly being operated as hotels with patients being referred to as clients and menus and plush waiting lounges being the norm. Mr. Manohar Parrikar would have to invest in infrastructure that would dwarf even the investment in IFFI. The medical Tourism policy would have to address the investment in the government hospitals and medical education. The policy would have to envisage the creation of health parks where subsidized land ,water and power be given to the private sector to set up multispeciality hospitals and research labs. Parrikars efforts to
replace the existing mediclaim with a sort of universal health insurance which allows a citizen of Goa to chose his health provider in the private or public sector within or outside the state, is an interesting step in the right direction. It would reduce the burden on GMC allowing it to concentrate on medical training and would encourage the private sector to invest in better and bigger hospitals in the state. It would also pave the way for standardisation and accreditation of medical establishments in the state, use of ICD codings and software etc.
This of course could expose Mr Parrikar to charges of misplaced priorities and neglect of public health. With the change in dispensation at the Center he would be reluctant to take such a gamble. Medical tourism would boost employment and increase revenues. In the long term the people of Goa would be able to assess premium healthcare at local prices. But if medical tourism continues to remain a subject of discussion only then Goa could very well miss the bus as it has happened in the area of IT.

The author is currently a visiting consultant KLES Hospital & MRC, Belgaum and a cleft surgeon with a New York based charity SMILE TRAIN. He has worked and trained in the NHS in UK and Belgium and maintains a private practice in Goa. He can be contacted at pascalpinto@satyam.net.in.