Topic 8: Alternative Medicine and MT

1. Objective

At the end of this chapter the student will be able to:

 Explain the nature and role of alternative medicine in medical tourism.

 Discuss the various types of alternative medicine in practice.
 Explain the role of ayurveda in context of medical tourism in India.

Introduction
The history of alternative medicine is a rather interesting one, and
has its origins in traditional methods of medicine. Alternative
medicine has been in existence since time immemorial. Being a
primeval science, this medicinal system has been known to man
since the early days of his time on Earth. Using natural ingredients
to prevent and cure most illnesses has perhaps been man’s greatest
foray into medical science. Traditional medical practitioners aimed
at prevention of diseases associated with an increase in resistance
of the human body. 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.”

Practiced for thousands of years, alternative medicine includes

systems like Acupuncture, Ayurveda and traditional Asian medicine.
Alternative medicine branches out from the Complementary and
Alternative Medicine (CAM) treatments and therapies. CAM is often
combined with formal, conventional medicine, integrating both
medical practices, in order to give the best results to patients. It can
be said that the earlier methods of medicine were attempted at
achieving a balance between bodily and natural energy. Energies
were sought as positive and negative energies, where positive
energies were to bring in happiness and health and negative
energies an incapacitation of resistance to face any ailments.
Matters of utmost importance in deciding therapies or treatments in
these earlier medical systems were factors like one’s lifestyle, one’s
habits of eating and one’s occupational pressures.
The earliest use of traditional remedies dates back to 2800 BC in
China. Practised all over the world in more than a hundred
disciplines, alternative medicine has aided medical tourism in an
unprecedented manner. Using alternative medicine and following
alternative medical practices not only removes any possible
additional affects of the illness but also increases the resilience of
the body. It is generally claimed that natural remedies are not only
less inimical to human physiology but they also help in retaining
body pliancy. Systems of natural, traditional medicines use a
combination of ingredients to restore the bodily constituents. In fact,
natural remedies are considered more as food, given their natural
constituents. Since alternative medicine is based on completely
natural methods and there is no usage of any chemicals, there is no
danger of any interference with the organic system. A holistic
approach as opposed to looking at a set of symptoms and a
treatment that delves into the root-cause of an illness are some of
the distinct and highly acknowledged features of alternative
medicine. It is also opined that widespread use of modern medicine
has deteriorated the immune system in the human physiology and
has resulted in these modern medicines becoming less effective. It
is also often said that alternative medicine is the only way to cure
some incurable diseases.

Brief History of Alternative Medicine

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. The real
objective was to identify the deterrents in the body system which
caused ailments, and strengthened the body’s immunity. The
therapies mainly incorporated self-care, lifestyle changes and
various preventive measures. The normal practices that were
followed in the early stages of the history of alternative medicine
include the extractions of the bark of willow trees. Many kitchen
ingredients were also used for treating patients. The treatments
were considered as the blessings of God, as it brought immense
relief to the writhing bodies and prayer was considered as one of the
strongest weapons in waging war against ailments.
Alternative Medicine & MT
Today, alternative medicine holds out the immense potential in
attracting medical tourists. For example, India is likely to become a
major hub for medical tourism, with revenues from the industry
estimated to grow from US$333 million in 2007 to US$2.2 billion by
2012, says a study by the Confederation of Indian Industry (CII) and
McKinsey. The major competitive advantages that India faces are
cost-effectiveness and traditional medical systems like Ayurveda
and Naturopathy. The world has witnessed the development of
many traditional as well as modern systems of medicine in the 20th
century. Path-breaking discoveries like penicillin, technological
advancements in modern surgery, major research advancement in
stem cell research and genetic structure, and the development of
traditional medical systems like traditional Chinese system of
medicine, Acupuncture, Osteopathy, Homeopathy, Ayurveda, Yoga,
Unani and others have all been a part of developments in the
omnipotent territory of global medicine. The major competitive
advantages that India has are cost-effectiveness and traditional
medical systems like Ayurveda and Naturopathy. The last few years
have seen countries with their own individual expertise attracting
tourists from all over the world and promoting medical tourism like
never before.

India

In India, medical tourism in alternative medicine has its ancestry in

South India and some places in North-Eastern India. Internationally
famed for its natural remedies and therapies, Kerala’s schools of
medicine have embraced Siddha, Naturopathy and Ayurveda in
treating their patients. These traditional medical practices are
estimated to attract high-end medical tourists from Europe and
Middle Eastern countries. The vital advantages that a country like
India faces with regard to medical tourism are its traditional
therapies like yoga and Ayurveda combined with tourist attractions
in states like Kerala and north-eastern states. Naturopathy, a
therapeutic system based on natural remedies, trusts natural
elements like air, water and sunlight, combined with therapeutic
massages and conditioning and toning of the human body.
Naturopathy believes that the human body has the capacity to heal
on its own, provided it is in a healthy environment.

With a holistic approach to well-being, Naturopathy believes that the

three physical entities – the physical body, the supernatural soul and
the mind – must be integrated through natural energies. “A recent
survey shows that 76% of global drugs are consumed by the USA
and European countries. Freedom from diseases and drugs can only
be achieved by living a natural life style.”

Ayurveda

Ayurveda is the science of living originated from the Divine Memory

of "Lord Brahma" in the time immemorial and practised by the
ancient 'Rishis' in India. It is not a mere medical system to detect
and cure ailments but the emphasis on prevention of ailments and
ethics on living to attain Physical and Mental happiness and
longevity. Ayurveda started more than 5,000 years ago. There are
glimpses of ayurvedic treatments and medicines in various ancient
scripts. The word Ayu means life and Veda mean knowledge or
science.

Ayurveda, the most ancient healthcare system, takes its ingredients

from nature. The use of herbs, materials like gold and mercury and
many household ingredients make this science easily accessible to
common man. Ayurveda claims to cure diseases like diabetes with
the aid of nature. The Siddha medical system, which is a part of
Ayurveda, employs herbs, minerals and advanced scientific
techniques under ancient principles of medical science to cure many
chronic diseases. It is named as one of the most complicated and
intricate forms of medicine. Siddha considers nature and man as
one essential entity. It claims that physiological characteristics like
human aging can itself be arrested with natural remedies.

An Ayurvedic resort combines relaxing resort holidays with Ayurvedic

treatments and massage. Kerala has been promoting panchakarma
and other auyrveda treatments for centuries. The picturesque
landscape of Kerala, its verdant forests and hilly tracts nurture an
abundance of herbs and trees, valuable ingredients in several
Ayurvedic medicines.
The ancient tradition of Ayurveda has been kept alive in Kerala by
the master Vaidyas. The main Ayurvedic Vaidyas belonged to just 8
families. And were named the Ashta Vaidyas on account of their
expertise.

The state tourism department has declared ayurveda to be one of

its major thrust areas. International travel writers and tour operators
are being introduced to the "wonders of ayurveda" through special
10-day rejuvenation camps, being hosted by the department.
Tourism is a major revenue earner for the state. Kerala attracted 1.9
lakh and 2.6 lakh international tourists in 1998 and in 1999
respectively. The flow of tourists is bound to pick up greatly in the
coming years thanks to ayurveda. Tourists who travelled to beaches
and sanctuaries for leisure and fun in Kerala now spend major part
of their holidays in ayurvedic resorts for "rejuvenation and
recharging."

Naturopathy has evolved medical tourism in India in more than one

ways. With its systems of medication using all natural ingredients to
restore the holistic disease-fighting nature of the human body, the
medicine has created increased chances of its own survival through
tourists from all parts of the world visiting India to reap its benefits.
With naturopathy and ayurveda along with the world-renowned
tourist attractions and heritage places, the tourism sector can grow
in leaps and bounds. Naturopathy in “KayaKalp”, a naturopathy
centre in Himachal Pradesh, run by the Vivekananda Medical
Research Trust in India has served medical tourists in detoxifying,
immunising and rejuvenating through Yoga, Pranayama,
Panchkarma, Meditation and Naturopathy. Its therapies are claimed
to be drug-less and extremely natural. Naturopathy takes the help of
Ayurvedic preparations for healing processes like Panchkarma and
improvement of blood circulation.

India’s pioneer in alternative therapy – medical tourism, Kerala, has

visitors from all over the world in the months of June, July and
August. These months are looked upon as the best period for cure of
bodily ailments through Ayurveda. High-quality medical facilities
provided at low prices are the main tourist attraction in Kerala. The
packages offered in these Ayurvedic spas include services like
Ayurvedic oil massages, powder massages, vegetarian diets,
detoxification programs and a lifestyle change. In fact, it is little
known that Ayurveda includes not just massages, but a whole
gamut of services like herbal and natural diet plans, natural healing
therapies, and therefore a full-fledged medical system.

Ayurveda Gram, a unique Ayurvedic Institution in Bangalore offers

Ayurveda in its wellness form to medical tourists. It offers services
like Customised Yoga, Pranayama, Meditation, and a vegetarian diet
to boost metabolism. Its sprawling campus full of medicinal herbs
and natural surrounds helps in the processes of cure for specific
ailments like Arthiritis, Spondilytis, Cholesterol, Sinusitis, Peptic
Ulcer and Obesity. Other therapies by Ayurveda Gram include Stress
Management therapies, Panchkarma and rejuvenation therapies.

AYUSH, the department of Ayurveda, Yoga and Naturopathy, Unani,

Siddha and Homeopathy was formed under the Indian Medicine
Central Council Act, 1970. One of the most recent awareness
activities undertaken by AYUSH was a health fair organised in parts
of Hyderabad, Chennai, Indore and New Delhi. AYUSH ensured that
the major Ayurvedic, Unani and Siddha manufacturers in India
participated in this health fair.

Another famous Ayurvedic centre in India is the C V N Kalari Centre

for Ayurveda. Kalari is one of the approved Ayurvedic centres
recognised by the Kerala Tourism Department. Kalari has its
customers from many foreign countries. The centre specialises in
Marma Chikitsa (the application of pressure on specific nerve points)
and other special practices of healing. Having both therapeutic and
rejuvenative aspects in them, these specialised healing procedures
take extensive help of Ayurveda to treat the ailing.

Some Ayurvedic resorts have formulated Ayurvedic kitchens that

help improve the effectiveness of oil treatments. Diet regimens,
detoxification programs and other processes that give a glowing
skin to the customer are very popular. Some of these Ayurvedic
resorts also arrange for cooking classes to help their customers
acquire and maintain the lifestyle that they are introduced to in
these spas and resorts. Ananda, an Ayurvedic Spa in the Himalayas
is one of the most famous destination resorts in India. It offers
specialty Ayurvedic packages like Aroma therapy massages,
reflexology programs for rejuvenation, stress release programs,
personalised Yoga sessions, body composition analysis and weight
reduction programs through Yoga and Ayurveda. Ananda claims that
its packages and therapies cure many ailments like headaches,
nausea, climatic disorders, facial paralysis, insomnia, asthma,
neuralgia and does general improvement of metabolism.

Treatments In Ayurveda
Ayurveda is an integral system of health, which does not separate
body from nature. This integral relation extends to medicine too.
The purity of nature, to a large extent, still exists in Kerala, which is
probably one of the reasons for Ayurveda to be preserved in the
traditional form in Kerala. It is still possible to find a few herbs for a
Kashayam in a typical Kerala household whereas almost nothing is
obtainable in the residential areas of other regions of the country.

Ayurveda emphasises on prevention and not on management of

diseases. From the chapters of daily routines and hygiene,
Hrudayam moves to methods for the prevention of diseases. It is
advised not to pollute body and mind with sins to be healthy. Use of
proper foods and food combinations, giving due consideration to
natural instincts, etc., are described next. In a similar vein, Charaka
Samhita dwells on activities destroying janapathams (communities).
It is important to recall that even environmental protection is
recognised as an important aspect of health. In today's world,
cleaning of pollutants accumulated in the body due to the modern
life style is even more important. Ayurveda suggests this through
Panchakarma.

In the treatment of diseases, Ayurveda adopts two distinct

modalities. Shamana is the one used to manage the symptoms of
the disease whereas shodhana is the one used to eliminate the
cause of the disease. Shamana methodology keeps the doshas at
their places but gradually bring down their negative influences by
the application of medicines. Shodhana removes ama (toxins) and
mala (waste) from the body and restores the balance of the doshas.
Panchakarma is the most important shodhana chikitsa.
Panchakarma constitutes pancha (five) karmas (actions) for
purifying the body, mind and consciousness. However, in its
application, panchakarma is not just the use of all of these methods
alone. It also includes a set of purvakarmas which prepares the body
to remove the toxins and paschatkarma which makos sure that the
person regains the digestive agni and a thorough rejuvenation of the
body is achieved.

The five procedures of panchakarma are: Vamana, Virechana, Vasti,

Nasya and Raktamoksha. Vamana is therapeutic vomiting or emesis;
Virechana is a purgation therapy with herbal laxatives; Vasti is the
term used for therapeutic enema with Ayurvedic preparations;
Nasya refers to the nasal administration of Ayurvedic preparations
and the cleansing procedure through nose and Raktamoksha refers
to the removal of doshas from blood with blood-letting. There are
several forms of Raktamoksha such as sucking with leaches, incision
on the skin, piercing into the flesh and lastly cutting the vein. The
kind of panchakarma advised depends on the physiological
condition of the person. Normally not all of the five procedures are
used to remove the toxins.

Panchakarma starts with selected purvakarmas which includes

Snehana and Swedana. Snehana refers to internal and external
oleation. Oil massages are done to cause superficial and deep
tissues to supple. This process nourishes the nervous system. This
can also be deeply relaxing. Swedana is therapeutic application of
steam to cause sweating. This process loosens the toxins and the
process can be accelerated by the addition of herbal preparations to
the steam. After a few (generally three to seven) days of
poorvakarma, the doshas are ready to be flushed out of the system
by one or more of the panchakarma procedures.

Panchakarma programme varies slightly from school to school. A

typical Panchakarma session begins with an abhyanga procedure.
Abhyanga is an Ayurvedic oil massage whereby one/ two
practitioners apply warm oil on the entire body. This helps to loosen
and facilitate the removal of accumulated doshas (vata, pitta or
kapha; the thridoshas of Ayurveda) and amas from the body.
Following this nurturing and relaxing treatment, the person rests
briefly and then receives swedana in a steam cabinet. Herbalised
steam dilates the srotas or channels of circulation, further loosening
and removing impurities through the skin and gastrointestinal tract.
After swedana, a herbal powder such as sandalwood, rose or vaca
powder is rubbed briskly on the skin. This helps circulation, removes
toxins from the skin and helps to pacify the imbalanced doshas.

For some, Sirodhara is suggested after swedana. Sirodhara is the

continuous pouring of warm oil to the forehead for approximately 25
minutes. This calms the mind and expands consciousness thereby
relaxing the entire body. Lastly, nasya drops are administered to the
nasal passages. These medicated oil drops help remove residual
doshas and toxins from the head and neck area. They balance prana
and thus promote clarity of perception. At the completion of the
session, the patient may shower and rest. Other procedures may be
recommended depending on the body condition. Rejuvenative
herbal preparations are suggested subsequently which can be had
as food supplement.

Ayurvedic massage is a form of treatment for various age-related

and other common disorders. Some of the advantages which can be
cited are pain relief, improved circulation, stress relief, better sleep,
flexibility, athletic performance and emotional benefits. Massage
therapy can soothe pain, relax stiff muscles, and reduce the swelling
that accompanies arthritis. Advocates claim that, with ayurvedic
massage, deep-seated toxins in the joints and tissues are loosened
and released into the system for elimination through natural toxin
release processes.

Scope Of Ayurveda In MT
Ayurvedic and Medical Tourism industries are likely to be the largest
beneficiary of 2010 Commonwealth Games and may gain by around
Rs. 800 crore, according to The Associated Chambers of Commerce
and Industry of India (ASSOCHAM).

In a Paper brought out by the ASSOCHAM on `Prospects for

Ayurvedic & Medical Tourism Industries during CWG 2010, it has
been predicted that ayurvedic industry would alone earn a business
of Rs. 500 crore and revenues prospects for medical tourism are
predicted for estimated amount of Rs. 300 crore. The job
opportunities that would arise for professionals of these two
promising industries are projected for 40,000 people.

Revenue generation for ayurvedic industry will be mainly driven

through Spa centres which mean pampering exterior of those
tourists that stay in various hotels, beginning 5 stars to 1 star.

The ASSOCHAM estimates are based on the assumption that over

1800 athlete participation would be bare minimum for 2010
commonwealth games in variety of sporting disciplines and tourist
arrivals for the people is projected for 6-7 lakh overseas visitors.

The countries of which maximum outflow of tourists would emerge

include UK, Canada, Australia, Malaysia, South Africa, Singapore, Sri
Lanka etc. and over 4 lakh domestic tourists from.

The Chamber paper hoped that keeping in view of India’s ancient

tradition of ayurveda and its low-cost medical tourism facilities,
apart form UK, Canada, Australia, Singapore, Malaysia, Sri Lanka a
large number of outside visitors from aforesaid countries would like
to take advantages of domestic ayurvedic and medical tourism
facilities/resorts.

The Chamber estimates reveal that each foreigner visiting India

during Commonwealth games is likely to spend Rs.10, 000 to Rs.35,
000/- in availing ayurvedic expertise in various spa and herbal
centers.

While, the medical tourism spending will be higher between Rs.

40,000-Rs.1,20,000 in view of cardiac surgery, bone marrow
transplant, etc., a bulk of tourists will spend in Ayurveda and related
treatments, said Mr. Dhoot.

Based on enquiries received by the ASSOCHAM through its various

workshops & seminars, various players in the hospitality industry
based in Delhi, NCR, Haryana, Rajasthan, Uttar Pradesh and
Uttarakhand are proposing to set up over 200 ayurveda, spa and
herbal centres to provide possible comforts to tourists and athletes
that will gather during the period.

Assocham Analysis on CWG Impact on Ayurvedic & Medical

Tourism
Business Ayurvedic Industry Rs. 500 crore Medical Tourism Rs.300 crore

Tourists Spending Rs.10,000-Rs.35,000/- Rs.40,000- Rs.1,20,000./-

Employment Opportunities 40,000 Ayurveda, spa & Medical Tourism Professionals

The domestic ayurvedic industry market size is currently estimated

at Rs.3000 crore which will go up to around Rs. 5000 crore in next 2
years in view of rising demand for ayurvedic therapy and products.
This industry would grow at a level of Rs.5500 crore after 2010 CWG
games are concluded. Neighbouring states ayurveda, spa and
medical tourism centres will also contribute in it, which is currently
dominated by Kerala and Karnataka, feels the Chamber.

The export potential of ayurveda is currently pegged at Rs 12,500

crore and approx. 20,000 units are involved in this field and the
main players include Dabur, Himalayas, Zandu, Baidyanath. In India,
there are approx. 380,000 registered medical practitioners of the
ayurvedic system as compared to about 700,000 modern medical
system.

The reputed private hospitals in Delhi and NCR like Fortis,

Moolchand, Sir Ganga Ram, Apollo, Noida Medicare, Metro,
Dharmshila, Max etc. can tap the large inflow of medical tourism.
Better connectivity from the games villages and hotels in Delhi will
also pave the way for these hospitals to contribute the medical
tourism sector. For the last several years, Apollo and Escorts have
treated over 1 lakh foreign patients.

According to ASSOCHAM estimates, the Indian spa industry is

expected to receive an investment of US$ 35 billion in the next 3-4
years. However, the profit margins in the spa industry was as high
as 60-65% and domestic spa industry is offering a mix of traditional
ayurvedic, as well as Chinese, Thai and Swedish healing techniques.

ASSOCHAM has also suggested that ministries of health and tourism

should jointly set up a separate Department and training institutes
to bridge the gap of skilled professionals in this field and also
authorise the ayurvedic and herbal centres.
Some of the major treatments in the ayurveda and spa centres
include rejuvenative programmes & therapy (Rasayana Chikitsa),
body immunisation and longevity treatment, body sudation (Sweda
Karma), panchakarma Treatment etc.

Status Of Ayurvedic Practices

In the early 20th century, Ayurvedic physicians began to organise
into professional associations and to promote their case for national
recognition and funding. This began to become a reality after Indian
independence in 1947.

Ayurveda is now a statutory, recognised medical system of

healthcare like other medical systems existed in India. The Central
Council of Indian Medicine (CCIM) governs and recommends policies
for the research and development of the system. In certain states in
India, Charak Samhita and Sushruta Samhita are included in the
curriculum of modem medical courses.

Ayurvedic practitioners have been appointed as Honorary Ayurvedic

Physician to the President of India. Every year on the occasion of
Dhanvantari jayanti, a prestigious Dhanvantari Award is conferred
on a famous personality of Medical Sciences including Ayurveda.
Today, Kerala is one of the states in India that promotes research
and practices of Ayurveda. This has been attributed to its well
established Ayurveda centers and Ayurveda pharmaceutical
companies, as also the presence of medicinal herbs and plants on
the Western Ghats mountain range that runs through the state.
There are many Ayurvedic centers (known as Vaidya shalas) all over
Kerala.

As a result of strong regulations in medical practice in Europe and

America, the most commonly practiced Ayurvedic treatments in the
west are massage, dietary and herbal [Link] the United States,
the National Institute of Ayurvedic Medicine (established by Scott
Gerson) is an example of a research institute that has carried out
research into Ayurvedic practices. Gerson has published part of his
work on the antifungal activities of certain Ayurvedic plants in
medical journals.

Several pharmaceutical companies and academic institutions in the

west have come into conflict with Indian academic institutions and
traditional Ayurvedic practitioners over the intellectual property
rights of herbal products researched by the western agencies. The
ayurvedic practitioners have known about the efficacy of such
products for centuries and so contend that they carry precedence
with regards to patent rights on such products.

On December 1993, the University of Mississippi Medical Center had

a patent issued to them by U.S patents and trademarks office on the
use of turmeric (U.S. patent No. 5,401,504) for healing.

The patent was contested by India's "Council for Scientific and

Industrial Research" (C.S.I.R) on the grounds that traditional
Ayurvedic practitioners were already aware of the healing properties
of the substance and have been for centuries, making this patent a
case of bio-piracy.

After a complex legal battle, the U.S. Patents and Trademarks Office
ruled on August 14, 1997, that the patent was invalid because it was
not a novel invention, giving the intellectual property rights to the
principle back to the traditional practitioners of Ayurveda.

The turmeric patent was just one of the hundreds that the several
academic organisations and Pharmaceutical companies in the west
have claimed by ignoring Ayurvedic knowledge. Vandana Shiva, a
global campaigner for a fair and honest Intellectual Property Rights
system, says patents on herbal products derived from Neem, Amla,
Jar Amla, Anar, Salai, Dudhi, Gulmendhi, Bagbherenda, Karela,
Erand, Rangoon-kibel, Vilayetishisham and Chamkura also need to
be revoked

Seven American and four Japanese firms have filed for grant of
patents on formulations containing extracts of the herb
Ashwagandha. Fruits, leaves and seeds of the Indian medicinal plant
withania somnifera have been traditionally used for the Ayurvedic
system as aphrodisiacs, diuretics and for treating memory loss. The
Japanese patent applications are related to the use of the herb as a
skin ointment and for promoting reproductive fertility.

In modern years, Ayurveda has achieved world-wide fame. People

are looking for a medicinal system that allows lowest intake of
chemicals, whose side effects and reactions are well identified.
Thus, alternate healthcare systems are becoming more fashionable.
Ayurveda, which is a total system including preservation of health,
avoidance and curing diseases, can be the best exchange to today's
medical sciences. A natural concord between Ayurvedic principles
and the human structure is the main factor for its efficiency.

The present man-made lifestyle has led to many health hazards. The
stress and tension of every-day life is a chief factor for many health
problems. Lack of exercise, tainted environment and climatically
inapt menu further sap away energy. Ayurveda rectifies these
health issues through therapy and massage. Ayurveda can lessen
the problems created by the hectic lifestyle we lead today. Hence
Ayurveda is a science that is gaining wide recognition and
international fame today. With its innate remedies Ayurveda has
grown into an absolute health-care system without any side effects.

China
The 3000-year-old method of traditional medicine in China has
gained popularity as the world’s most popular medicine, being used
by more than a quarter of the world in treating even chronic
diseases like cancer, AIDS, allergies and heart diseases.

Traditional Chinese Medicine (TCM) uses medicinal herbs,

therapeutic exercises and acupuncture to cure ailments. TCM
diagnoses illnesses based on the five elements theory and the yin-
yang theory. The five elements theory base their evaluation on the
five elements – wood, fire, earth, metal and water to establish a
connection between human physiology and pathology and the
natural environment. The movement of these five elements
constantly rules the functioning of the human body and thus
establishes the interdependence of both.

The yin-yang theory calls for comprehending the bright and dark
sides of the universe, in other words, the opposite properties of the
universe. The relative nature of yin and yang represents the
interrelationship between substance and function. As traditional
Chinese medical practitioners say “Only with ample substance can
the human body function in a healthy way; and only when the
functional processes are in good condition, can the essential
substances be appropriately refreshed.”

Chinese herbal medicine is more known as Chinese materia medica.

This includes Chinese crude medicine, prepared drugs in pieces,
traditional Chinese patented medicines and simplified Chinese
medicinal preparations. Chinese herbology, a major aspect of TCM
addresses the art of combining medicinal herbs. It visualises the
entire human body’s balance of energies and spirit to treat a
medical condition. Herbs are combined into different potions of
various characteristics for the sake of different individuals being
treated by TCM practitioners. Herbs like Astragalus, Ginkgo, Ginger,
Green Tea, Siberian Ginseng and Garlic are used to treat several
ailments. Around 300 mineral and animal extracts and 400 formulae
are used to cure diseases, in Traditional Chinese Medicine.

Acupuncture, as part of TCM is used to unblock the flow of vital

energy through the human body. One of the oldest healing
techniques in the world, this traditional method aims at “restoring
health through simulation of specific points on the body.” Ailments
like nausea, addictions and some kinds of pains are claimed to be
treated with the help of acupuncture.

Taking advantage of its abundant human resources, China is luring

medical tourists into its web of alternative medical therapies.
Wellness packages in China come at low costs and without any side-
effects, thanks to proliferated Traditional Chinese Medicine. Several
massages and spas have been set up in recent times that provide
mental health and physical well-being to medical tourists with the
help of Chinese medicinal herbs. Wellness apartments are
established for the purpose of serving senior medical tourists. These
wellness apartments facilitate these tourists in practicing their own
hobbies and also conducting medical activities like Taiji.

Germany
Germany’s alternative medical practices have their origins in
Homeopathy, a medical system that was developed by Samuel
Hahnemann, a German physician.

Homeopathy considers symptoms as disturbances of vital forces

that have a connection with the human body. Homeopathic
advocators believe that this medical system has the ability to cure
acute diseases like flu, cold, pains, depression and fatigue,
constipation, irritability other than chronic diseases. It is claimed to
cure allergies and allergic disorders like Eczema and Asthma.
Moreover, this medical system is child-friendly, in the sense, that
the medication given by homeopaths is sweet to the tooth and
therefore acceptable. Homeopaths are known for debonair and their
hands-free treatment of patients. They concentrate more on the
patient’s state of mind and attitude towards life. The preparation of
different potions in Homeopathy is done mostly with the help of
herbs, minerals and animal extracts. Also, it is often reasoned that
since the dosage that homeopaths prescribe is in such minute
constitutions and because they come in dilutions of substances like
water and alcohol there is no chance of any side-effects. Germany
also stands famous for its herbal remedies. Regulated by
Commission E14 on the purity and pharmaceutical activity, these
herbal medicines in Germany have come a long way in preventing
and curing many diseases like cancer, AIDS and other serious
ailments. Most physicians in Germany are required to be educated
in Alternative therapies, so that it serves complimentary to modern
medical treatments.

With more than 300 spa towns, Germany has become the premier
destination for health and wellness in Europe. One of the most
famous resorts in Germany is the Baltic Spa Resort in Warnemunde.
Situated on the shore of the Baltic Sea, it idealises the sea as a
“homeopathic pharmacy” and claims that “it contains all important
trace elements and has a similar composition to human blood” Sea
water is said to have revitalising effects in treating bodily ailments
like respiratory illnesses, sleep disorders and obesity. Other than
these, mental disorders like depression, anxiety and agony are
claimed to be cured with the help of the sea. The sea breeze is said
to be specifically effective in treating cardio-vascular as well as
dermatological conditions. Major advantages that Germany faces
are in terms of both cost and quality. In the US, operations are four
to five times more expensive as they are in Germany.

Japan
Japanese medicine is known as Kanpo or Kampo, a herbal medicine
that forms part of well-researched modern clinical methods and also
traditional methods of medicine. A Japanese variant of the
traditional Chinese medicine or the Oriental medicine, Kanpo
adheres to the body’s natural instincts and natural mechanism of
healing. For this purpose, medical treatment involves the diagnosis
of the tongue, abdomen and pulse. At each stage of the treatment,
different formulae that are necessary to bring the body back to
normalcy, are prepared by the physician. These herbal medicines
are regulated by the Japanese Government. Kanpo medicine is used
to cure many acute and chronic ailments like cardio-vascular,
respiratory, digestive, reproductive and dermatological conditions
and immune system corrections and even disorders like bedwetting,
high cholesterol and hepatitis.

Though Kanpo therapies take longer than usual to work, this medical
system uses some very natural diagnosis and treatment methods
and concepts like water, blood and air to identify bodily symptoms.
Also, it is claimed that these herbal medicines produce no side-
effects because of their natural compositions. Japanese therapists of
Anma visit countries like India and Singapore to help in the
promotion of health tourism. Anma, a traditional Japanese massage,
is said to be a complete form of Shiastu that treats the body to
release blood flow in a proper manner to rejuvenate the body.

Apart from attracting tourists for its natural herbal medical

treatments, Medical tourism in Japan has become popular thanks to
its volcanic areas that have allowed the formation of some hot
mineral water springs called Onsen. Japanese Onsen serves as
places where the ailing can get alternative treatments to modern
medical practices. These have medicinal properties that heal
wounds, alleviate pains and replenish energy levels. Senior tourists
and people suffering from many kinds of aches and pains come
flocking to these mineral water springs. The healing properties of
these springs are accentuated by the surrounding volcanic soil that
is composed of many minerals and curative elements.

Outlook of Medical Tourism in Alternative Medicine

Alternative medicine is here to stay, claim 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. Natural medicines like herbs and
minerals can all be partaken as food and not medicines as such,
since their composition is all natural. Alternative medicine is used in
conjunction with modern medicine to treat many chronic ailments
like diabetes and AIDS. This helps modern medical practitioners to
evolve a closer relationship with the patient and cure him to a
greater extent, thus giving him a new perspective on life. It follows
that one should never overlook the disposition of the traditional
cures suggested by our ancestors. These provide a standpoint from
where one can comprehend the profundity of traditional and
alternative medicine, and gauge the tremendous potential of
alternative medicine in medical tourism.

Summary
Some of the key points of this chapter are as following:

 Naturopathy believes that the three physical entities – the physical body, the
supernatural soul and the mind – must be integrated through natural energies.
 Ayurveda uses herbs, materials like gold and mercury and many household
ingredients make this science easily accessible to common man.
Topic 9: Medical Tourism in Kerala
1. Objective

At the end of this chapter the student will be able to:

 Explain the potential of Kerala in medical tourism

 Discuss the various ayurvedic treatments provided in the state of Kerala
 Discuss the growth of medical travel industry in Kerala

Medical Tourism In India

Medical Tourism industry according to CII is expected to be worth
US$ 4billion by 2017. India has a potential to attract 1 million health
tourists per annum which will contribute US$ 5 billion to the
economy. Patients from various countries are becoming medical
tourists to India for low cost and health restorative alternative
treatments. The Medical Tourists undergo health restorative
treatments of a combination of Ayurveda, Yoga, acupuncture, herbal
oil massage, nature therapies, and some ancient Indian healthcare
methods –such as Vedic care, an alternate healthcare service. Cost
Advantage is the attractive aspect of Indian modern medicine which
is 10-15 times lower than anywhere in the world. The CII-McKinsey
report suggests that medical tourism could fetch as much as $2
billion by 2012, compared to an estimated $ 333 million in 2006-07.

Kerala is a prime high-end tourism destination in the Indian sub-

continent and has been rated as “one of the fifty destinations to be
visited in one’s lifetime” by the National Geographic Channel (2004).
Moderate climate, rich art, colorful festivals, diverse natural and
cultural attractions with a physical quality of life comparable to
developed nations are causing tourism industry to flourish in Kerala.
Compared to the other states in India, Kerala is unique for its
interesting geographical diversity it possesses within the smallest
area possible. This diversity offers tourists a rage of attractions and
experience such a beaches, backwaters, wildlife sanctuaries,
evergreen forests and diverse flora and fauna of Kerala. It is often
projected as the “Green Gateway” to India (Netto, 2004).

Kerala’s share of international tourists coming to India has increased

from 5.54 percent in 1994 to 8.85% percent in 2005 making it a
leading state for tourism in the country. Earnings from tourism are
also projected to grow at a record level of more than 23.5 percent
which is very high than earnings growth projected for India and
world average which is 14.3 percent and 6.5 percent.

Table 1. International & Domestic Tourists Arrivals (Source:

Department of Tourism,
Government of Kerala, Tourist Statistics, 1994, 2002, 2006)
 Year International Tourist Domestic Tourists

1994 104568 1284375

1996 176855 4403002

1998 189941 4481714

2000 209893 5013221

2002 232564 5568256

2004 345546 5972182

2006 428534 6271724

Table 2. Kerala’s share of foreign tourists to India (Source:

Department of Tourism,
Government of Kerala, Tourist Statistics, 1994, 1998, 2002,
2004)

Year India Kerala % Share

1994 1886433 104568 5.54

1996 2287860 176855 7.73

1998 2358629 189941 7.68

2000 2649378 209893 7.92

2002 2384364 232564 9.75

2004 3367980 345546 10.26

International tourist arrivals to Kerala had reached almost half

million in 2006, and is expected to cross 5 lakh by 2007. For the
domestic tourism, the arrivals had crossed 60 lakhs in 2006. This
almost meets the prediction of world Travel and Tourism Council
(WTTC) that with an average annual arrival growth rate of 18% for
domestic tourists and 12% for international tourists Kerala is
becoming one of the fastest growing destinations in the world
(WTTC, 2002). The growth of domestic and international tourism in
Kerala and its relative position in the Indian tourism in the recent
past is depicted in tables 1 and 2.

Relevance Of Health Tourism In Kerala

Kerala is an established tourist destination. Ayurveda is already
popular and Kerala is recognised as the number one source for
Wellness solution. The Alternative medicine sector led by Ayurveda
has been showing vibrant growth in recent years. There is also
tremendous scope for Modern medicine including Dentistry in the
state.

Some Reasons for Travel of Foreign Patients to India/Kerala:

1. UK NHS—National Health Service for poor citizens is heavily

burdened and the system almost collapsed. Indian costs being only
1/6 of UK attracts the lower and middle-income groups to India.

2. In the U.S. the cost of medical treatment is so high that only

10% can afford the costs in US, while Indian costs are only 1/10.
3. The Middle East: Huge infrastructure facilities are available. But
the expertise is insufficient. After 9/11, they have reduced trips to
U.S.

Role of CII

India and Kerala have only private institutions participating in

Medical Tourism. CII has been attempting to bring several medical
institutions under one umbrella. They have already succeeded in
bringing 40 hospitals under the umbrella of medical tourism. CII
started medical tourism promotion in Kerala with 12 hospitals. Some
of them are Lakeshore, Amrita, Medical Trust, MIMS, Baby Memorial,
KIMS, Ananthapuri, Uthradom Thirunal, EMS Coop. Hospital etc. CII
recently completed a study on the Scope of Medical Tourism in
India. The study says that the medical tourists in modern medicine
at present is hardly 12,000 to 16,000. (This is exclusive of Ayurveda
which is already about 3.5 lakhs.) By 2012 it will hit 1 million visitors
to India. Out of this Kerala’s target is 20%, i.e.2 lakhs. It is expected
that in 5 to 10 years Medical tourism will overtake other forms of
tourism.

1. Ayurveda in Kerala Medical Tourism

Ayurveda is a synonym for Medical Tourism in Kerala. There has

been a spontaneous growth in Kerala for Ayurveda, which has no
competition in the whole world. By unorganised but collective effort
the name Ayurveda got branded all over the world.

Ayurveda seeks to treat the body holistically and tackles not merely
the symptoms but the root cause of the illness, thus restoring the
body to good health. Ayurveda in Kerala is an established branch of
treatment and there are many Ayurveda resorts and Ashrams where
the medical tourist can find licensed practitioners of Ayurveda, with
years of experience in treating patients.

By eliminating toxins, reviving immunity and rejuvenating the body

Ayurveda effectively treats many chronic conditions. Ayurveda is
also used in beauty therapy to rejuvenate and refresh the body and
revitalise the skin tone. Medicinal oils containing the beneficial
extracts of plants, are applied to the body by trained Ayurvedic
masseurs. The combination of the massage and the medicinal
properties of the oils help restore the patient to health, relieves
stress, eliminates toxins and rejuvenates the body.

Some of the conditions in which Ayurveda is particularly effective

are stress relief, spondylosis, slipped disc, sports injuries, bone and
joint problems and back injuries. Ayurvedic therapies such as
Abhyanga, Dhara, Elakizhi, Nasyam, Pizhichil, Njavarakizhi, and
Udhwardhanam are used in Ayurveda in Kerala.

Ayurveda Resorts In Kerala

Kerala, the land of Ayurveda, is the place where all the reputed and
recommended Ayurvedic Centres are located. The following
Ayurvedic Rejuvenation Centres, which are serving the humanity all
over the world and rendering this science called Ayurveda with
distinction:

Coconut Holidays Resort:

These Centres are offering various therapies along with

Accommodation. Therefore one can combine Ayurvedic therapy
treatment with the tour of 'Gods' own country 'Kerela'. At all these
below mentioned properties which come under the casino group of
hotels provides excellent Ayurvedic Treatments and hence are
highly recommended. Casino Hotel (Cochin), Coconut Lagoon
(Kumarakom), Spice Village (Periyar), Bangaram Island Resort
(Lakshadweep), Spice Cost Cruises (Puthenagadi), The Marari Beach
(Mararikulam), Anjali Hotel (Kumarakom) and The Brunton Boat Yard
(Cochin).

Kairali Health Resort:

Kairali is undoubtedly a resort with a difference. set amidst 50 acres

of lush greenery in Palakkad, kerala, popularly referred to as "god's
own country", Kairali promised to be a singular chapter in any
tourist's Indian experience. The nearest airport is Cochin, which is
just an hour and half drive form Kairali. Kairali Ayurvedic health
resort is dedicated to bringing you the benefits of science that has
proved to work wonders for health over 5000 years based on
traditional oil massages, this ayurvedic health system has had wide
acceptance both as a general health and rejuvenation plan which
are completely free of any toxicity and side effects. The resort also
boasts of a yoga & meditation centre.

They provide therapies as under:

 Special Ayurvedic health programme for weight - loss (07,

14 & 21 days)
 Proven remedies for arthritis & spondylitis (07, 14 & 21
days)
 Post pregnancy health programme (07, 14 & 21 days)
 Special Treatment for sinusitis & migraine (07, 14, & 21
days)
 Rejuvenation therapy to restore vigour & vitality (07, 14, &
21 days)
 Special package to remove stress & strain (03, 07 & 14
days)
 Beauty care & eye care package (03, 07, 14, & 21 days)

Keraleeyam Ayurvedic Resort:

Alappuzha (Alleppey) is 1 hour 30 minutes drive by road from

Cochin airport or 3 hrs drive form Thiruvananthapuram or
Trivandrum Apt. A short 15 minute ferry boat cruise from Alappuzha
boat jetty will take you to Keraleeyam. It has a very long backwater
frontage. The atmosphere at Keraleeyam is that of a traditional
home. Keraleeyam is housed in an ancient Kerala home built 70
years back.

Manal Theeram Beach Resort:

It is just 9 kms from the world renowned tourist centre, place in the
sun, Kovalam, 21 kms south of Trivandrum.

Sanjeevanam Resort:

Sanjeevanam, The simple and comfortable procedure of

rejuvenation therapy practised in Ayurveda comprises of Pizhichil,
Dhara, Avisnanam etc. It offers the following benefits: Restores the
energy reserves of the body, reduces stress, strain and fatigue,
relieves body aches, slows down the ageing processm builds
resistance to diseases, improves complexion and skin texture,
reduces, subcutaneous fat & controls obesity. The therapy takes 30
minutes to 90 minutes per day. Longer the duration better and more
sustained, the effects.

Somatheeram Resort:

A perfect hideaway, far from mass tourism. nine kms south of the
renowned Kovalam Beach and 21 Kms from the state capital
Trivandrum. The pristine charms of nature in its primordial best,
wedded to the elegance of a resort – Somatheeram is a fascinating
haunt.

Somatheeram has an exclusive ayurveda centre, where several

rejuvenative therapies based on the vedic science ayurveda (5000
years old traditional indigenous body toning practice) are possible,
Ayurvedic Treatment with herbal preparations directed towards
strengthening the immune system, preventing and curing disease
without any side effects. It is also known for its reputed yoga centre
where yoga and meditation can be learned and practiced under the
guidance of a yoga guru.

Thirummal Resort:

Thirummal - short duration ayurvedic rejuvenation therapy -

duration 30 minutes, experience the wonderful rejuvenative effect
of ayurveda in 30 minutes, at Keraleeyam, Thirummal can give you
an instant burst of energy that lasts several days.

Keraleeyam offers wide range of therapies. The duration of each

procedure depends upon the each individual and is at the discretion
of the Ayurvedic doctor.

Special Beauty therapy takes care of pimples, wrinkles acne,

sagging of the skin and a falling of hair. The oil nourishes and
cleanse the tissues to make the complexion glowing & youthful,
smoothes wrinkles & enhances beauty. The eye care treatment
helps in relieving tension i the eye which causes poor eye sight,
pain, fatigue, it brings luster to the eyes and smoothes away
wrinkles.
Ayurveda Definition
Ayurveda is a holistic system of medicine from India that uses a
constitutional model. Its aim is to provide guidance regarding food
and lifestyle so that healthy people can stay healthy and folks with
health challenges can improve their health.

Origin

Ayurveda is an intricate system of healing that originated in India

thousands of years ago. We can find historical evidence of Ayurveda
in the ancient books of wisdom known as the Vedas. In the Rig Veda,
over 60 preparations were mentioned that could be used to assist
an individual in overcoming various ailments. The Rig Veda was
written over 6,000 years ago, but really Ayurveda has been around
even longer than that. What we see is that Ayurveda is more than
just a medical system. It is a Science of Life. We are all part and
parcel of nature. Just as the animals and plants live in harmony with
nature and utilise the Laws of Nature to create health and balance
within their beings, we, too, adhere to these very same principles.
Therefore, it is fair to say that Ayurveda is a system that helps
maintain health in a person by using the inherent principles of
nature to bring the individual back into equilibrium with their true
self. In essence Ayurveda has been in existence since the beginning
of time because we have always been governed by nature's laws.

Meaning

Ayurveda is made up of two Sanskrit words: Ayu which means life

and Veda which means the knowledge of. To know about life is
Ayurveda. However, to fully comprehend the vast s cope of
Ayurveda let us first define "Ayu" or life. According to the ancient
Ayurvedic scholar Charaka, "ayu" is comprised of four essential
parts. The combination of mind, body, senses and the soul.

In Ayurveda every person is a unique individual made up of five

primary elements. The elements are ether (space), air, fire, water,
and earth. Just as in nature, we too have these five elements in us.
When any of these elements are present in the environment, they
will, in turn, have an influence on us. The foods we eat and the
weather are just two examples of the presence of these elements.
While we are a composite of these five primary elements, certain
elements are seen to have an ability to combine to create various
physiological functions. Ether and air combine to form what is known
in Ayurveda as the Vata dosha. Vata governs the principle of
movement and therefore can be seen as the force which directs
nerve impulses, circulation, respiration, and elimination. Fire and
water are the elements that combine to form the Pitta dosha. The
Pitta dosha is the process of transformation or metabolism. The
transformation of foods into nutrients that our bodies can assimilate
is an example of a pitta function. Pitta is also responsible for
metabolism in the organ and tissue systems as well as cellular
metabolism. Finally, it is predominantly the water and earth
elements which combine to form the Kapha dosha. Kapha is what is
responsible for growth, adding structure unit by unit. Another
function of the Kapha dosha is to offer protection. Cerebral-spinal
fluid protects the brain and spinal column and is a type of Kapha
found in the body. Also, the mucosal lining of the stomach is another
example of the Kapha dosha protecting the tissues. We are all made
up of unique proportions of Vata, Pitta and Kapha. These ratios of
the doshas vary in each individual; and because of this, Ayurveda
sees each person as a special mixture that accounts for our
diversity.

Ayurveda gives us a model to look at each individual as a unique

makeup of the three doshas and to thereby design treatment
protocols that specifically address a persons health challenges.
When any of the doshas (Vata, Pitta or Kapha) become
accumulated, Ayurveda will suggest specific lifestyle and nutritional
guidelines to assist the individual in reducing the dosha that has
become excessive. We may also suggest certain herbal supplements
to hasten the healing process. If toxins in the body are abundant,
then a cleansing process known as Pancha Karma is recommended
to eliminate these unwanted toxins.

Treatments In Ayurveda
Ayurveda is an integral system of health, which does not separate
body from nature. This integral relation extends to medicine too.
The purity of nature, to a large extent, still exists in Kerala, which is
probably one of the reasons for Ayurveda to be preserved in the
traditional form in Kerala. It is still possible to find a few herbs for a
Kashayam in a typical Kerala household whereas almost nothing is
obtainable in the residential areas of other regions of the country.

Ayurveda emphasises on prevention and not on the management of

diseases. From the chapters of daily routines and hygiene,
Hrudayam moves to methods for the prevention of diseases. It is
advised not to pollute body and mind with sins to be healthy. Use of
proper foods and food combinations, giving due consideration to
natural instincts, etc.,

are described next. In a similar vein, Charaka Samhita dwells on

activities destroying janapathams (communities). It is important to
recall that even environmental protection is recognised as an
important aspect of health. In today's world, cleaning of pollutants
accumulated in the body due to the modern life style is even more
important. Ayurveda suggests this through Panchakarma.

In the treatment of diseases, Ayurveda adopts two distinct

modalities. Shamana is the one used to manage the symptoms of
the disease whereas shodhana is the one used to eliminate the
cause of the disease. Shamana methodology keeps the doshas at
their places but gradually bring down their negative influences by
the application of medicines. Shodhana removes ama (toxins) and
mala (waste) from the body and restores the balance of the doshas.
Panchakarma is the most important shodhana chikitsa.
Panchakarma constitutes pancha (five) karmas (actions) for
purifying the body, mind and consciousness. However, in its
application, panchakarma is not just the use of all of these methods
alone. It also includes a set of purvakarmas which prepares the body
to remove the toxins and paschatkarma which makos sure that the
person regains the digestive agni and a thorough rejuvenation of the
body is achieved.

The five procedures of panchakarma are: Vamana, Virechana, Vasti,

Nasya and Raktamoksha. Vamana is therapeutic vomiting or emesis;
Virechana is a purgation therapy with herbal laxatives; Vasti is the
term used for therapeutic enema with Ayurvedic preparations;
Nasya refers to the nasal administration of Ayurvedic preparations
and the cleansing procedure through nose and Raktamoksha refers
to the removal of doshas from blood with blood-letting. There are
several forms of Raktamoksha such as sucking with leaches, incision
on the skin, piercing into the flesh and lastly cutting the vein. The
kind of panchakarma advised depends on the physiological
condition of the person. Normally not all of the five procedures are
used to remove the toxins.

Panchakarma starts with selected purvakarmas which includes

Snehana and Swedana. Snehana refers to internal and external
oleation. Oil massages are done to cause superficial and deep
tissues to supple. This process nourishes the nervous system. This
can also be deeply relaxing. Swedana is therapeutic application of
steam to cause sweating. This process loosen the toxins and the
process can be accelerated by the addition of herbal preparations to
the steam. After a few (generally three to seven) days of
poorvakarma, the doshas are ready to be flushed out of the system
by one or more of the panchakarma procedures.

Panchakarma programme varies slightly from school to school. A

typical Panchakarma session begins with an abhyanga procedure.
Abhyanga is an Ayurvedic oil massage whereby one/ two
practitioners apply warm oil on the entire body. This helps to loosen
and facilitate the removal of accumulated doshas (vata, pitta or
kapha; the thridoshas of Ayurveda) and amas from the body.
Following this nurturing and relaxing treatment, the person rests
briefly and then receives swedana in a steam cabinet.

Herbalised steam dilates the srotas or channels of circulation,

further loosening and removing impurities through the skin and
gastrointestinal tract. After swedana, a herbal powder such as
sandalwood, rose or vaca powder is rubbed briskly on the skin. This
helps circulation, removes toxins from the skin and helps to pacify
the imbalanced doshas.

For some, Sirodhara is suggested after swedana. Sirodhara is the

continuous pouring of warm oil to the forehead for approximately 25
minutes. This calms the mind and expands consciousness thereby
relaxing the entire body. Lastly, nasya drops are administered to the
nasal passages. These medicated oil drops help remove residual
doshas and toxins from the head and neck area. They balance prana
and thus promote clarity of perception. At the completion of the
session, patient may shower and rest. Other procedures may be
recommended depending on the body condition. Rejuvenative
herbal preparations are suggested subsequently which can be had
as food supplement.

Ayurvedic massage is a form of treatment for various age related

and other common disorders. Some of the advantages which can be
cited are pain relief, improved circulation, stress relief, better sleep,
flexibility, athletic performance and emotional benefits. Massage
therapy can soothe pain, relax stiff muscles, and reduce the swelling
that accompanies arthritis [citation needed]. Advocates claim that,
with ayurvedic massage, deep-seated toxins in the joints and tissues
are loosened and released into the system for elimination through
natural toxin¬ release processes.

Some of the prime body treatments and body care in

Ayurveda are given as under:

Abhyangam (14 Days):

Special type of oil massage in which strokes are given according to

the diseases for 45 minutes per day for 14 days. This treatment is
very useful for Obesity, especially for Diabetic Gangrene etc.

Dhanyamla Dhara (14 Days):

Warm herbal liquid is poured all over the body in a rhythmic way
through a special vessel for 45 minutes to 1 hour daily. This
treatment is very effective for hemiplegia, Paralysis Rheumatic
complaints etc.

Dhara (14 Days):

In this process, some Herbal oils, medicated milk, medicated butter

milk etc. are poured on the forehead in a special method for about
45 minutes in a day for a period of 7-21 days. This treatment is
mainly for Insomnia, Vatha Predominated diseases, Mental tension
and certain skin diseases.

Kativasthi:
In this process specially prepared warm medicated oil is kept over
the lower back with herbal paste boundary, This treatment lasts for
45 minutes to 1 hour and it is good for any type of back pain and
spinal disorders.

Kizhi (14 Days):

Herbal leaves and herbs or herbal powders are applied to the whole
body in boluses with hot medicated oils for 45 minutes per day for a
period of 7 to 14 days. This treatment is for osteoarthritis, arthritis
with swelling, spondylosis, sports injuries etc.

Ksheeradhoomam:

This is fomentation with medicated cow milk. This treatment is good

for facial paralysis.

Bell's palsy, speech disorders and other nervous disorders of the

face.

Lepanam:

This is a process by which medicated herbal paste is applied on the

affected part, This is useful for various types of inflammatory
conditions.

Nasyam (14 Days):

Herbal juices, medicated oils etc. are applied through nose for 7 to
14 day. This treatment is highly effective for certain kinds of
Headaches, Paralysis, Mental disorders, some types of skin disease
etc.

Njavarakizhi (14 Days):

It is a process by which the whole body or any specific part thereof

is made to perspire by the application of certain medical puddings
externally in the form of Boluses tied up in muslin bag. This is
applied by two to four therapist for abut 60-90 minutes per day for a
period of 14 days. This Treatment is for all types of Rheumatism,
Pain in the Joints, Emaciation of limbs, High blood pressure,
Cholesterol and certain kinds of skin diseases.
Pizhichil (14 Days):

In this treatment, lukewarm herbal oils are applied all over the body
by two to four trained therapists i a special rhythmic way
continuously for about 60 to 90 minutes per day for a period of 7 to
21 days. This treatment is very useful for Rheumatic diseases like
Arthritis, Paralysis, Hemiplegia, Sexual Weakness, Nervous
Weakness and Nervous disorders etc.

Sirovasthi (14 Days):

Certain lukewarm herbal oils are poured into a cap fitted on the
head for 15 to 60 minutes per day according to the patients
conditions for a period of 7 days. This treatment is highly effective
for facial paralysis, Dryness of nostrils, mouth and throat, Severe
headaches, and other Vatha originated diseases.

Snehapanam (14 Days):

Mediated Ghee is given internally in a proportionally increased

quantity for a period of 8 to 12 days. This treatment is for
Osteoarthritis, Psoriasis, and Leukemia etc.

Thalam:

Special powder mixed with medicated oil applying on the top of the
head for 20 to 45 minutes. This treatment is helpful for ENT
problems, insomnia, migraine etc.

Udvarthanam (14 Days):

This is a typical massage with herbal powder for about 30 to 45

minutes daily for a period of 14 to 28 days. This treatment is for the
diseases like Hemiplegia, Paralysis, Obesity and certain Rheumatic
ailments.

Urovasthi:

Like Kativasthi warm medicated oil is kept over the chest for 45
minutes this is an effective treatment for asthma, other respiratory
problems hearth diseases and muscular chest pain
Vasthi (14 Days):

Certain herbal oils, herbal extracts etc. are applied through the
rectum daily for a period 5 to 25 days. This Treatment is for Arthritis,
Paralysis, Hemiplegia, Numbness, Gastric complaints associated
with Rheumatism and constant constipation.

Yoni Prakshalanam (7 Days):

Herbal oils and decoctions are applied through the vaginal route.
This treatment is good for gynecological disorders. It is also a
purification process for genital organs.

Conclusion

This understanding that we are all unique individuals enables

Ayurveda to address not only specific health concerns but also offers
an explanation as to why one person responds differently than
another.

Dental Care In Kerala

Dental Care in Kerala is a cost-effective alternative for residents of
western countries and nations in the Middle East. The extremely
high cost of dental care in these nations has prompted many Indians
and residents of these countries to travel to Kerala in search of a
better solution.

Dental Care in Kerala draws upon the large manpower of trained

dentists and nurses who provide international quality services at
very reasonable prices. With over 3000 dentists and 1200 dental
clinics, Kerala has a distinct advantage in dental tourism. The fact
that the treatment requires multiple sittings with liberal gaps in
between sittings and hence requiring around 30-40 days stay makes
the dental patient an ideal candidate for medical tourism.

Table 3.
Dental procedure Cost in USA ($) Cost in India ($)

General Dentist Top End Dentist Top End Dentist

Smile designing - 8,000 1000

Metal Free Bridge - 5,500 500

Dental Implants - 3,500 800

Porcelain Metal Bridge 1,800 3,000 300

Porcelain Metal Crown 600 1,000 80

Tooth impactions 500 2,000 100

Root canal Treatment 600 1,000 100

Tooth whitening 350 800 110

Tooth colored composite fillings 200 500 25

Tooth cleaning 100 300 75

Tourists can avail of world-class treatments including specialised

periodontal treatment, orthodontic and prosthodontic treatments at
dental care centers, dental clinics and hospitals in Kerala. From
routine dental procedures such as root canal treatment and surgical
extraction of impacted wisdom teeth to cosmetic dentistry
procedures, such as tooth realignment and smile designing, dental
care in India offers a complete range of medical solutions to medical
tourists from around the world.

With well-equipped clinics and hospitals, Dental Care in Kerala has

proved to be one of the most popular forms of medical tourism to
Kerala. With modern equipment, a completely sterile environment,
the use of disposable syringes and gloves, and international
standards of treatment, dental care in Kerala now draws large
numbers of medical tourists every year. Eager to receive
personalised treatment of an international standard at an affordable
price medical tourists have been increasingly exploring the options
offered by dental care in Kerala India.

Dental care procedures offered by centers specialising in

dental care in Kerala, include:

 Tooth Extractions and Implantation

 Root Canal Treatment
 Crowns and Bridges
 Denture Fitting
 Periodontal Care
 Cosmetic Dentistry
 Smile Designing

All major hospitals in Kerala offer dental care. There are also a large
number of privately run dental clinics across Kerala India.

Allopathic Treatment For Medical Tourists In Kerala

Beside Ayurveda, Kerala has an endless array of experienced
allopathic medical professionals and well equipped hospitals that
offer treatments of international standard at a very reasonable
price. Previously, Indians especially Keralites working in foreign
nations such as in Gulf countries always visit Kerala for medical
treatment as it doesn't have much affect on their kitty.

Nowadays, even the patients of other countries has started choosing

Kerala as a destination for treatment of various diseases due to
some special advantages. Kerala has good transportation facility. It
is well connected to several Middle East European and Southeast
countries by air. Even it has good number of hospitals and renowned
specialised doctors in most of the disciplines. Along with these
facilities, Kerala's climatic condition and the communication skill of
its natives helps Kerala to be the most sought after destination for
medical treatment in the entire nation.

Patients from around the globe settled for Kerala as because the
charges of major surgical procedures like cardiac surgery, dentistry,
and cosmetic surgery is very low in comparison to developed
western countries. The medical professionals of Kerala provides
good pre and post-operative care to their patients so that they can
have a positive experience. After the treatment at the hospitals,
patients can stay at some famous health resorts of Cochin,Varakala,
Kovallam and many more places of Kerala.

Cardiac Care in Kerala is a branch of medicine that attracts many

patients from around the world. Patients from the Gulf countries, Sri
Lanka and from many other countries are coming to India to
experience the excellence of Cardiac care in Kerala.

With specialty hospitals, extremely well-trained doctors and nursing

staff, and the quick scheduling of surgery, cardiac care in Kerala has
proved to be an attractive medical tourism option for many
patients.

Some of the hospitals that offer world-class cardiac care in Kerala,

are the Trichur Heart Hospital, and the Sree Sudihindra Medical
Mission Hospital in Cochin. The Sri Chitra Thirunal Institute in
Thiruvananthapuram is another renowned research and treatment
facility.

With hospitals equipped with the latest equipment including Color

Doppler Echocardiography and Nuclear Scanning hospitals in Kerala
offer advanced cardiac care procedures such as minimally invasive
surgery, angioplasty, bypass surgery and interventional cardiac
catherisation. With well-trained teams of Cardiologists, cardio-
thoracic surgeons and anesthesiologists, specialty hospitals in
Kerala are the preferred choice of cardiac patients, worldwide.

Cardiac surgery is also very reasonable in Kerala compared to

international rates. The complete cost of airfare to India,
 hospitalisation, pre and post operative care, doctors fees and
recuperation put together is between 1/3 to ½ the cost of similar
surgery in most western nations, where a long waiting list of cases
also has a negative impact on the health of the patient.

Table 4: The following table gives a very brief comparative

picture of the price
of the treatment.

Procedure USD (in USA) USD(in India) Difference in Price

Bone Marrow Transplant 250000 69200 28%

Liver Transplant 300000 69350 23%

Heart Surgery 30000 8700 29%

Orthopedic Surgery 20000 6300 32%

Cataract Surgery 2000 1350 68%

Dental Procedure

Metal Free Bridge 5500 600 11%

Dental Implants 3500 900 26%

Porcelain Metal Bridge 3000 600 20%

Porcelain Metal Crown 1000 100 10%

Apart from Kerala there are many excellent cardiac care centers in
India. The Narayana Hrudayalaya in Bangalore, Manipal Heart
Foundation in Karnataka, the Escorts Heart Hospital in Delhi and the
Apollo Hospitals across India, are internationally known for the
quality of their cardiac care in India.

General Surgery for a variety of medical conditions is a branch of

medical treatment in Kerala that has attracted patients from around
the world. General Surgery in Kerala is the preferred choice of
patients because of the excellent hospitals with well-trained doctors
and nurses. The quality of pre- and post-operative care and the very
reasonable cost of general surgery in Kerala are other positive
factors leading to the growth of this branch of medical tourism in
Kerala.

Routine thoracic, abdominal and pelvic surgery, as well as surgery

to correct musculo-skeletal conditions and the removal of abnormal
growths etc, are some of the general surgical options offered at
hospitals in Kerala India. The hospitals are equipped to deal with
critical care, and trauma victims as well as victims of chronic
conditions that require surgical intervention. General Surgery in
Kerala has found its place on the medical tourism map of the world.

With well-equipped operation theatres, trained trauma and critical

care teams and the back-up support of labs and blood banks,
hospitals in Kerala focus on providing complete medical care
solutions. General surgery in Kerala is one of the specialised
branches of medicine that has become a sought after medical
tourism option.

Some of the hospitals that offer general surgery in Kerala are:

 Atingal Multispeciality Hospital, Trivandrum

 Specialist's Hospital, Ernakulam
 Champakara Multispeciality Hospital
 Amrita Institute of Medical Sciences & Research Centre,
Ernakulam
 Carewell Hospital & Research Centre Pvt. Ltd, Kasargod

Orthopedic Treatment in Kerala

Orthopedic treatment in Kerala is a branch of medicine that has

become a preferred choice of patients with orthopedic conditions.
Patients from all over India and around the world come to Kerala for
orthopedic treatment. Traditionally Ayurvedic massage therapy has
been used to treat a variety of orthopedic conditions. But as
hospitals and clinics specialising in modern medicine have
developed, today orthopedic surgery and orthopedic treatment in
Kerala offers the latest treatment options in state-of-the-art medical
centers in Kerala.

Orthopedic treatment involves the diagnosis and treatment of

medical conditions affecting the skeletal system. Disorders of the
bones and joints, and conditions of the spine are treated at
orthopedic centers in Kerala. Orthopedic surgery such as hip
replacement, knee replacement and Spinal surgery and treatment of
fractures by Ilizarov techniques are offered by hospitals providing
orthopedic treatment in India.

With fully-equipped operation theatres, trained orthopedic care

teams and the back-up support of labs and blood banks, hospitals in
Kerala focus on providing complete medical care solutions.
Orthopedic treatment in Kerala is one of the specialised branches of
medicine that has become a sought-after medical tourism option.

Fertility Treatment in Kerala is a specialised treatment offered at

a large number of hospitals and clinics in Kerala. Assisted
reproduction programs offer parents who are unable to conceive,
the hope of having biological children with the assistance of modern
technology.

Assisted Reproductive Technology (ART) is provided at specialised

hospitals that offer Fertility Treatment in Kerala. The treatment
program includes medical checkups of the couple, to determine the
physiological causes of infertility. After the cause is determined the
appropriate assisted reproductive technique is prescribed.

Advanced techniques such as GIFT (Gamete Intra Fallopian Transfer)

and ZIFT (Zygote Intra Fallopian Transfer) are offered at well-
equipped Fertility centers in Kerala. With fully-equipped laboratories,
ultrasound equipment and experienced doctors and support staff,
fertility treatment in Kerala is economically priced and has been a
sought-after treatment option by many Indian residents of the
Middle East Countries.
The positive results of fertility treatment in Kerala has led to more
couples making the trip to Kerala to take advantage of the medical
expertise on offer. Some of the hospitals and clinics that offer
fertility treatment in Kerala are:

Amritha Institute of Medical Science & Research Centre, Ernakulam

Sree Chitra
Tirunal Institute of Medical Science, Trivandrum Atingal
Multispeciality
Hospital, Trivandrum Specialist's Hospital, Ernakulam
Asha Maternity & General Hospital, Kollam

Suggestions For Improvement Of MT In Kerala

Ayurveda in Medical Tourism

Ayurveda is a synonym for Medical Tourism in Kerala. There has

been a spontaneous growth in Kerala for Ayurveda, which has no
competition in the whole world. By unorganised but collective effort
the name Ayurveda got branded all over the world. The present
problem in the market is the overcrowding of unqualified people
conducting massage parlors in the name of Ayurveda. If immediate
measures are not taken to control such fake set ups, the tourists
who come in search of genuine Ayurveda treatment will get cheated
and carry back a wrong message about Ayurveda. This is especially
so because Ayurveda is not very strong in standardisation and
scientific data. Another problem facing Ayurveda is the scarcity of
certain essential herbs and medicines, which will affect the quality
of the treatment.

Environment and Infrastructure

The physical environment includes the improvement in basic

infrastructure, standard of cleanliness etc. Basic amenities should
be good, toilets should be user-friendly and well maintained. Good
standards at lesser cost will make the state a more attractive, value
for money destination. For this we have to improve the physical
infrastructure and connectivity. The social environment includes the
improvement in human culture and behavior. People have to be
friendly to the visitors and guests. Our old manthra, ‘Athidhi devo
bhava’ or ‘guest is equal to god’ is very relevant in this context. We
should have a responsible political culture. The overcrowded
schedules of Harthals and strikes will spoil the image of Kerala as a
tourist friendly state.

Medical & Legal Aspects

Medical Tourism in India is a growing trend, with increasing numbers

of patients from Europe, the Middle East and India's neighboring
countries coming to India for specialised treatment at very
reasonable prices.

Certain medical and legal aspects of medical tourism need to be

kept in mind, since Medical Tourism to India is still a very new field.

Medical Visa: The Government of India has recently authorised a

new category of visas for prospective medical tourists. This Medical
Visa will enable patients who wish to travel to India for medical
reasons, to enter India on this specialised visa, and stay for the
duration of their treatment.

Medical Insurance: This is another area about which patients

should remain informed. Currently, medical insurance firms in the
West may not recognise treatment at a hospital in India as part of
their medical insurance policy. Thus a patient may have to fund his
or her own treatment, which could be a significant amount, though
still far less than the same treatment in a privately run hospital in
the west.

Legal Issues: The legal aspects of medical tourism are undefined

at present. All medical procedures carry an element of risk. Even
routine surgery may sometimes lead to medical complications. A
patient may be unsatisfied with the results of their surgery or
medical treatment, and wish to seek legal recourse. Currently there
is no international legal regulation of medical tourism. As medical
tourism increases worldwide, it is likely that an international
regulatory authority will come into being. If an international legal
framework were to come into place then issues of jurisdiction
between a patient's home country and the country where the
medical treatment was availed can be resolved.

Growth Of The Medical Tourism Industry In Kerala

Kerala, known as ‘God’s Own Country’, has always been at the
forefront of India’s Tourism industry and a torchbearer of the
‘Incredible India’ campaign globally. Trade, Hotels and Restaurants
(including Tourism) contributed 21.72 per cent to the state’s GSDP in
2004-05. The total revenue (including direct and indirect) from tourism
during the period January-December 2007 was Rs.11,433 crores.
Travel and tourism generates 6.2% of total employment. Around 1
million people are employed in this sector in Kerala.

There has been a significant growth in the number of both foreign

and domestic tourist arrivals into the State, which has exceeded 7
million in 2007. World Travel and Tourism Council (WTTC) estimates
tourism demand of Kerala is to grow by 11.6% per annum over the
next decade. A growth of 23.5% is predicted in terms of external
account earnings from travel and tourism over the next 10 years
(India's estimates for this period are 14.3% while the world average
is only 6.5%), thus making Kerala an important hub of tourism in
India and the world.

The promotion of Kerala as an international medical tourism

destination ensures huge opportunities in investments for the Non-
Resident Keralites (NRKs), making it a venture that holds great
promise. The main purpose behind this is to introduce Kerala as an
international tourism location by 2010.

The government is willing to aid NRK investors in every way

possible. However, only those hospitals which abide by the terms of
the National Accreditation Board (NAB) would succeed in receiving
government recognition.

Kerala has surprised the populace with the astounding growth that it
has seen in tourist traffic, i.e., a growth of 31% in 2005. According to
“Opportunities in Medical Tourism in India (2007)” (a RNCOS report),
Kerala has been the most preferred travel destination, particularly
 for those seeking Ayurvedic rejuvenation. The hospitals in Kerala are
also setting up special divisions and support systems for their global
patients.

Table 5: Policy Initiatives in the Tourism sector

Government Initiatives in
Initiatives in the new
Thrust in Medical Tourism
Tourism Policy
the Tourism Sector

• The key selling points of • Non-requirement of approval

• An investment of Rs.100 bn
the medical tourism industry for foreign equity of up to 51% in
in Hospitality sector proposed.
are its cost effectiveness tourism projects.
and its combination with the
An Investment to the tune of
attractions of tourism, • NRI Investments allowed up to
Rs.50 bn by 2012 in support
traditional therapies and 100%.
of infrastructure Investment is
treatment methods.
proposed.
• Approvals for Technology
• Most of the modern agreements in the hotels industry
• Plans to rope in Culture,
treatment facilities that can on automatic basis.
Health, Forest, Irrigation,
be avaited Kerala are cheaper
Electricity and Fisheries
by 40-50% when compared to • Concession rates on goods that
departments for the overall
other countries. are required for initial setting up
development of the sector.
of facilities.
Are underway.
• Kerala Health Tourism, by
2010, would enjoy at least • Approved hotels are entitled to
• Plans to set up Special
20% market share of medical import essential goods relating to
Tourism Zones (STZs) along
tourism in India. the hotel and tourism industry up
the lines of the special
to the value of 25% of the foreign
economic Zone are underway.
exchange earned by them.

Conclusion

During the last decade, tourism in Kerala has made a spectacular

performance. From 1999 onwards, consecutively for three years,
Kerala Tourism has got the Best Performing Indian State award.
Some of the main tourism development initiatives taken by Kerala
which enabled it to become one of the leading destinations
internationally are:
  Focused marketing efforts within a limited budget,
developed in active partnership with private sector,
leading international travel firms and agencies.
 Early lead in formulating comprehensive tourism policy,
guiding and setting long-term vision and goals for the
tourism sector growth.
 Successful differentiation of the destination using effective
positioning strategy, and benchmarking the performance
with the neighboring leading international destinations, in
the process, developed a distinct image as a stand-alone
destination from India and the rest of the states.
 Development of an array of tourism products of world-class
appeal mostly based on resources available locally. Added
to these, the socio-economic context of Kerala defined by
the high level of social development and the contrasting
industrial backwardness turned out to be a perfect setting
for promoting Kerala as an unspoiled destination with
exotic characteristics. In most parts of Kerala, the
movement from an agrarian society to the present day
information society was bypassing the intermediate stage
of the industrial society (Govindan, 1996).

Summary
Some of the key points of this chapter are as following:

 Kerala is a prime high-end tourism destination in the Indian sub-continent and has
been rated as “one of the fifty destinations to be visited in one’s lifetime” by the
National Geographic Channel (2004).
 Kerala’s share of international tourists coming to India has increased from 5.54 per
cent in 1994 to 8.85% per cent in 2005 making it a leading state for tourism in
the country.
 Ayurveda emphasises on prevention and not on management of diseases.
 General Surgery for a variety of medical conditions is a branch of medical
treatment in Kerala that has attracted patients from around the world. General
Surgery in Kerala is the preferred choice of patients because of the excellent
hospitals with well-trained doctors and nurses.
Topic 10: Impact of Medical Tourism on Public
Health
1. Objective

At the end of this chapter the student will be able to:

 Explain the impact of medical tourism on public health.

 Describe the challenges of the medical tourism industry.
 Explain the economic potential of the medical travel industry.

Introduction
Although there are distinctly new trends and patterns emerging in
contemporary times, international travel for health purposes has
had an extensive history. From as early as the Neolithic period,
people have traveled long distances to specific geogra geographic
locations across Europe in order to conduct rituals and for other
perceived health benefits. Indeed this practice continued in varying
forms throughout medieval times, where by the 18th century the
upper strata of European classes often traveled across borders in
order to bathe in thermal springs for medical purposes. (Goodrich,
1993)

However, in contemporary times medical tourism occurs both across

and between both richer and poorer countries and is motivated by a
variety of elements such as: cost of treatment; quality of services;
length of waiting time; and availability of complementary and
alternative medicine.

Expansion of Medical Tourism in India

Even the Government of India has responded promptly to tap the

potential of this sector. In its effort to capitalise on this opportunity
the Government has untaken measures to promote India as a
“global health destination”. The National Health Policy 2002 strongly
encourages medical facilities to provide services to users from
overseas. It states that “providers of such services to patients from
overseas will be encouraged by extending to their foreign exchange,
all fiscal incentives, including the status of “deemed exports”, which
are available to other exporters of goods and services”.

The Indian Ministry of Tourism has started a new category of visas for
the medical tourists. These visas called the “M” or medical-visas are
valid for one year but can be extended up to three years and are
issued to a patient along with a companion. Efforts have also been
undertaken to improve the airport infrastructure to ensure smooth
arrival and departure of the health tourists.

A brochure of the ministry predicts a “phenomenal expansion” of

the Indian health-care industry in the coming years.

These factors have favored the recent spurt of growth of medical

tourism in India. Official figures indicate that medical tourists from
55 different countries come to India for treatment. While most of
these patients are from developed countries, India is also seeing a
surge of patients from countries in Africa and South and West Asia
that lack adequate healthcare infrastructure. Among others, foreign
health travelers to India comprise of a large number of non-resident
Indians (NRIs). If the present trend continues trade in health and
health-services will become one of the biggest sectors in India.
However, there are several challenges that could impede the growth
of medical tourism in India, more importantly the growth of this
sector poses a threat to the already crippled public health system in
India.

The privatisation and ' corporatisation ' of healthcare has created

medical tourism where people from rich nations travel to Third
World countries to obtain medical care, experience and enjoy the
tourism attractions and use other resources. It is a 'magic lamp' for
those countries to attract overseas patients and earn foreign
exchange. According to a study by the Confederation of Indian
Industry (CII) and McKinsey, medical tourism will bring $2.2 billion in
revenues for Indian hospitals by 2021.

India is promoting medical tourism in the following way, as stated in

its National Health Policy of 2002: 'To capitalise on the comparative
cost advantage enjoyed by domestic health facilities in the
secondary and tertiary sector, the policy will encourage the supply
of services to patients of foreign origin on payment. The rendering
of such services on payment in foreign exchange will be treated as
"deemed exports" and will be made eligible for all fiscal incentives
extended to export earnings.' This formulation shows the influence
of the corporate sector, as does the 'Policy Framework for Reforms
in Healthcare' which was drafted by the prime minister's Advisory
Council on Trade and Industry.

India's corporate hospitals are meeting the requirements of

international standards, with the cost of treatment about one-eighth
to one-fifth of that in the US or the UK. Therefore, many foreigners
are flocking to India to get affordable and high-quality healthcare.
Treatment in India is 'cost-effective' for patients from rich countries
because there is no clear-cut differentiation between Indian and
foreign patients in place in India, and medical-care costs are
exorbitant in their home countries.

Local People's Access To Health Care

Due to the medical tourism boom, private hospitals are expanding
and demand more human resources. More and more qualified
medical professionals from the public sector and small towns or
hospitals are attracted to the metropolitan health centres. Even
now, most of the professionals in the private institutes have
migrated from government institutions and will remain available
only for foreign tourists and Indian elites. Seventy per cent of the
rural population do not have access to proper healthcare and
many choose to not seek any treatment at all as the charges
imposed by private practitioners are far beyond their financial
capacity. On the other side, however, the Indian Ministry of Health is
accrediting hospitals and recommending prices for their services to
guarantee service quality for medical tourism.

For medical tourism, only large specialised hospitals run by

corporate bodies are promoted to enhance their opportunities
beyond the limited domestic 'market'. Indian private healthcare
costs are likely to rise as the number of medical tourists increases.
Even before the medical tourism boom in India, healthcare was
becoming increasingly expensive. In 1987, the cost of a single
treatment in the public health sector in Kerala was 16.6 rupees, but
this rose to 830.7 rupees in [Link] growing attention given to
medical tourism, quality healthcare will probably become
unaffordable for the common person.

Emigration of Indian medical professionals to other countries is

common. Due to medical tourism, Indian institutions may be capable
of providing remunerative salaries which will attract back the
'drained brains' (reverse migration). But the new manifestation in
the form of medical tourism is just 'brain drain plus'. This requires
the skilled person to stay back within the country, get marginally
higher wages, use infrastructure and other resources from his/her
own country and contribute his/her whole energy to serving
foreigners. In addition, the poor Indian taxpayers have to finance the
training of these professionals since the latter acquire their
expertise from government institutions.

This provides a much higher surplus to the developed-country

economy. However, this argument has been countered by the
contention from industry that medical tourism is serving to stem the
external flow of healthcare professionals to foreign countries.
Medical Tourism’s Economic Potential
Firstly it is contended that it will increase export earnings through
attracting foreign exchange into the country, hence lowering fiscal
deficit and assisting the growth of the national economy.

Secondly, it is argued that the combination of increased medical

technologies and the growth of health specialists and greater levels
of expertise will generally raise the standards of healthcare across
the country through competitive market practices, which will
eventually translate to an increase of the standards in the public
sector. (Bookman & Bookman, 2007) Although in general the
media, government and private sectors are maintaining medical
tourism will improve the public healthcare system and health status
of the population, rhetoric surrounding the methods in how this will
be achieved is either absent or employs the widely critiqued notion
of the “trickle-down” concept. The general assertion made is that
economic growth derived from medical tourists will be siphoned
back into hospitals, improving the technology and equipment, which
will benefit the population at large.

Thirdly, it is argued that the economic growth medical tourism could

generate would result in an overall increase of national income, thus
creating equity in access through allowing more of the population
access to private care. (Henderson, 2004; Turner, 2007)

Despite these arguments, it has been widely acknowledged that

many economic development programs implemented in the past
have been extremely detrimental to different sectors of the
population through the disregard for their social effects. Regardless
of this acceptance there are many elements of medical tourism,
specifically when viewed as a facilitator of economic development,
which echo past development outlooks. Firstly, the high-tech nature
of most medical tourism brings it association with modernism,
placing it in prominently and positively in the public eye, serving as
an example of the of a nation’s “development”. This is argued to
draw attention away from faltering public health systems and public
health via a distortion of priorities. (Bookman & Bookman,
2007:176)
Challenges And Threats Of The Expansion Of MT In India
The present growth in medical tourism in India has been
encouraging but to sustain this growth and to achieve it full
potential certain challenges have to be addressed. It is also
important to understand the impact of the growth in this sector on
the public healthcare delivery so that necessary corrective
measures can be undertaken.

Create inequitable health systems

Three decades after the Alma-Ata Declaration, “health for all”

remains an unattainable goal in India. In sync with the fundamental
principle of primary healthcare, the government has developed an
extensive network of health facilities but regrettably the system has
failed to deliver.

The nemesis of the public healthcare in India has been compounded

by low government expenditure on health as well as by factors such
as poor management of resources, acute shortage of skilled
workforce, large-scaled absenteeism, corruption and conflicting job
roles. These factors along with several policies of the government
(such as release of prime building land at low rates, exemptions
from taxes and duties for importing drugs and high tech medical
equipment and concessions to doctors setting up private practices
and nursing homes) have helped in the unabated growth of the
private sector.

The private sector has gained a dominant presence and today it

accounts for 82% of outpatient visits, 58% of inpatient expenditure,
and 40% of births in institutions. A study conducted by global
accounting and consulting firm Ernst and Young and the Federation
of Indian Chamber of Commerce (FICCI), shows that the private
hospitals in India earned Rs. 62,000 crore in fiscal year 2006 and
revenues from the sector are expected to rise up to Rs. 130,000
crore in 2012, which represents an annual revenue growth rate of
about 19% a year. In comparison to this public healthcare system in
India has been seriously underperforming.
As per NSSO estimates between 1995–96 and 2004, the utilisation
of government sources of treatment (including public hospitals,
PHC/CHC, public dispensaries, ESI doctors, etc.) increased from 19%
to 22% in rural India and declined from 20% to 19% in urban India.

For hospitalised treatment, the decline in utilisation of government

sources was from 43.8% to 41.7% in rural areas and from 43% to
38.2% in urban areas. The inadequacies in the public health sector
have also stunted its growth and tarnished its potential of being a
product that could be offered on an international market.

The underutilisation of the public health system coupled with the

growth in the private sector will increase the disparities and poses
as a major threat of medical tourism in the Indian context. The real
challenge to expanding medical tourism as a strategy for economic
growth and development will be to identify and implement
mechanisms that prevent the development of a dual and inequitable
health system with enclaves of high-quality health facilities catering
to foreign visitors; and foster mutually beneficial linkages between
the private and public health sectors, and between state-of-the-art
health services and community health.

Intensify shortages of skilled health professionals

An important reason for poor service delivery in the public sector is

the shortage of trained and skilled health personnel. According to
the recently released Planning Commission report, India is short of a
phenomenal 600,000 doctors, 1 million nurses and 200,000 dental
surgeons. With positions of 300,000 dental surgeons, only 73,000
are currently full. Meanwhile, 1.1 million nurses are filling up
vacancies for 2.1 million, a shortfall of nearly 50%. To aggravate
matters, there is also a huge paucity of paramedical staff including
radiographers, X-Ray technicians, physiotherapists, laboratory
technicians, orthopedists and opticians. The report also highlights
the highly skewed distribution of the available manpower towards
the urban areas.

The availability of medical specialist in local Community Health

Centers, compared to the sanctioned posts, is also disquieting. The
existing CHCs have a high shortfall of specialist manpower, such as
obstetricians and gynecologists (56%), pediatricians (67%),
surgeons (56%) and medical specialists (59%), with no provision of
anesthetists. Such acute shortages of medical professionals in India
is ironic as the country has approximately 229 medical colleges with
an annual admission capacity of over 25 600 students.

There are several factors that could explain the shortage of doctors
in the public system. These include bottlenecks in the recruitment
process, poor financial incentives, the absence of a conducive work
environment and the prevalence of corruption in the public health
sector.

While the public sector is encumbered with staff and resource

shortages, it has been estimated that over 75% of the human
resources and advanced medical technology, 68% of the estimated
15,097 hospitals and 37% of 623,819 total beds in the country are in
the private sector. These figures suggest that the private sector is
the prime employer of health personnel predominantly trained in
public health institutes. This also sounds an alarm that further
growth of the private sector could aggravate the manpower crunch
in the public sector.

An important expectation of increased trade in health services is

that through the increased opportunities locally and regionally, it
would encourage and facilitate a greater retention of skills in the
region. However, considering that at present the growth is restricted
to the private, it may not be a viable solution to the manpower
crunch in the public sector.

Raise quality of care and accreditation issues

Variation in the quality of care provided and the asymmetry of

information between providers and consumers regarding quality is a
concern in the health service sector. A major reason for the
underutilisation of the public health services in India is the lack of
prescribed standards of quality. Still it remains a neglected area
within the realms of government policies.

The quality of services is also one of the main arguments against

medical tourism. In response to this, the Government and CII have
taken the lead in the process of national accreditation and licensing
for the private sector. The WHO supported Joint Commission
International (JCI) has accredited 10 institutions in India, all of them
being in the private sector. The process is underway to encourage
other private healthcare facilities, including laboratories, diagnostic
centers, outpatient clinics, and day surgery centers in the country,
to attain JCI to accreditation.

Thus initiatives are being undertaken to standardise the quality of

services in the private sector but they have completely bypassed
the public sector facilities. This is disconcerting and is suggestive of
the lack of government initiative to improve services in the public
sector.

Promote unregulated growth of the private sector

There are several concerns that arise from the growth of the private
sector and the government is supposed to play an important role in
regulating this sector. However, in India, State interventions have
been minimal, leaving the sector to grow laissez-faire. In India, there
is no policy framework to have a common set of regulations for the
private healthcare sector. The implementation and enforcement of
the existing regulation have been weak and many of these
regulations have not been updated and hence have lost their
relevance. The State does not consider concerns related to private
sector growth as a high priority on the policy agenda. There are no
institutional mechanisms within the government to address the
private sector issues. Moreover, there has been considerable
resistance from various constituents of the private healthcare sector
to accept in principle the applicability of certain regulations to their
profession.

This lack of regulation has allowed the private sector in India to

grow unabated and has resulted in mounting dissatisfaction with the
services offered by this sector along with an increase in cases of
medical negligence.

A major challenge in the promotion of the medical tourism in India

will be to institutionalise and harmonise regulations within the
private sector in the country. This is essential as if the present
conditions persist there will be no quality control over the services
provided. Besides, the present circumstances will promote
mushrooming of super-specialty institutes providing health services
to medical tourist and wealthy Indians, and monopolise the available
human and material resource in health.

Increase cost of medical treatment

As per NSSO 60th Round, during 2004, 24% of the episodes of

ailments among the poor were untreated in rural areas and 22% in
urban areas. Lack of finances was cited as a reason by 28% of
persons with untreated episodes in rural areas and 20% in urban
areas.

The health insurance market in India is very limited covering about

10% of the total population. Out-of-pocket payment by individual
household is the main source of healthcare financing and accounts
for 72% of all health expenditures. Around 24% of all people
hospitalised in India in a single year fall below the poverty line due
to hospitalisation.

Lack of insurance cover has also worked as a major disincentive for

the growth of medical tourism. However, there have been recent
developments that could help address this constraint. Insurance
providers are currently expanding their network to include physician
around the globe, and it is anticipated that within a decade a
majority of large employers’ health plan will include offshore
medical centers. Already in India, US-based private health insurers
Blue Cross and Blue Shield and British health insurer Bupa, now
insure clients treated at a number of private hospitals in India. The
option of health insurance is set to boost the growth of medical
tourism in countries like India.

A trade-off of the increase in medical tourists will be the rise in the

overall cost of healthcare in the country. Several studies have
indicated the rising nature of the medical costs in recent years.
According to their estimates, between 1995–96 to 2004, there was
an increase of 55.67 and 77.28%, respectively, for government and
private sources in rural India. In urban India, the corresponding
increase has been, respectively, 76.6 and 116.2%. Such increases in
cost will make medical treatment unaffordable and will further
increase the percentage of untreated individuals.

Raise medical liability issues

The provision of medical services is fraught with uncertainty of
health outcomes and informational asymmetries. Difficulties by
patients to ascertain provider qualifications, and to know the
appropriate level, type, and cost of care required will be a challenge
to expansion of health tourism. It would be necessary to establish a
system that could deal with any legal liabilities associated with
treating international patients. The issue of medical liability is
equally pertinent for the public sector. An important challenge will
be to develop a system to address medical liabilities, which also
includes the services provided in the public health sector.

Conclusions And Recommendations

The current demand for health and wellness services has generated
a global market in the health services. In India, the private sector
has responded promptly to this demand, which is evident from the
recent increase in the number of super-specialty centers offering
services to medical tourists. Even the government has initiated
measures to encourage growth of medical tourism but these have
mainly benefited the private sector, leaving the public sector
unaddressed.

There are several factors that favor India as a hub for health related
services, which include world-class medical expertise, competitive
costs, well-equipped health facilities, no waiting period etc. Trade in
health and health related services, has been predicted to evolve into
a billion dollar industry in India. However, as outlined above there
are challenges and the growth of medical tourism could pose as a
threat to the public health system in India.

The threats could arise from intensified manpower shortage in the

public sector, creation of inequitable health systems in the private
and public sectors, increased cost of treatment and unregulated
growth of private health facilities. To counteract these threats and
to ensure that medical tourism has a favorable impact on the public
health system, it will be necessary to undertake certain measures.
The following are some recommendations that could help minimise
the threats and maximise the benefits of the expansion of trade in
the health sector:

1. Harmonisation of regulations within the country: It will be

necessary to develop specific regulations for the health sector,
improve transparency and ensure complete implementation. The
regulations should restrict the uncontrolled growth of private sector
institutes, maintain a standardised quality of services and maximise
the utilisation of the available resources.

2. Addressing the availability of skilled health professionals: The

mal-distribution of human resources between private and public
sectors is a concern and has been elaborated above. As a
consequence of medical tourism, it is expected that job
opportunities within the private sector will increase, leading to
further migration of trained professionals to this sector. In order to
confront the challenge, the public sector should readdress issues
related to employee dissatisfaction and provide better incentives to
retain its staff. There is also a need to increase the number of
trained health professionals. Efforts have already began in this
direction and the 11th five-year plan envisages setting up of
six AIIMS like institutions, upgrading 13 existing medical institutions,
establishing 60 new medical colleges and 225 new nursing colleges.
It is also expected that increased trade may induce repatriation and
retention of health professionals to work in private or public sector
ventures.

3. Reduce variation or gaps in quality of care provided in both the

public and private sectors: An important reason for the
underutilisation of the public sector institutions is the poor quality of
services. Instituting a common minimum standard of care could
improve the uptake of services in the public sector and reduce the
dependence on the private sector. Hence, a system to undertake
national accreditation and licensing should be planned and
implemented. The Indian Medical Association and Medical Council of
India could play a pivotal role in this regard working through the
Joint Commission International (JCI).

4. Increase the coverage of health insurance: As few health

insurance plans offer clients insurance coverage for non-emergency
medical treatments obtained overseas, the need to pay out-of-
pocket for services provided abroad could limit the market to those
who can afford to pay. While efforts have already begun to increase
medical insurance options for overseas clients, similar efforts should
also be undertaken to popularise alternative systems of health
financing such as community-based health insurance, capitation,
vouchers and social health insurance etc., for the treatment of poor
patients.

5. Identifying and implementing mechanisms that will prevent the

development of a dual and inequitable health system with enclaves
of high quality health facilities catering to foreign visitors. The
government is responsible for providing good quality care to their
citizens, and policies and strategies to expand and foster greater
trade in this area should support, and be complementary to national
healthcare efforts. In addition, strategies should foster mutually
beneficial linkages between the private and public health sectors,
and between state-of the art health services and community health.
An effort should be made to encourage the utilisation of the services
provided in the public sector for the purpose of medical tourism.

6. Establish a system that can address legal liabilities associated

with medical treatment. This is important as consumers will have
less of an incentive to come to India for treatments if legal recourse
is difficult. If such a system is instituted, it will be important to
ensure that it is also sensitive to the grievances of the indigenous
patients.

7. Establish, reactivate or strengthen mechanisms that can

facilitate public-private sector partnerships. There is a need to
provide support to local entrepreneurs in the development of viable
business plans for expansion of spa/wellness services, and in
development public-private partnerships, including careful market
analysis.

8. Because of the dearth of information regarding the number,

origin, expenditures, and characteristics of tourists who may be
coming to India for health and health-related services, it is highly
encouraged that a tracking system be developed, implemented and
maintained. As part of this effort, it may be useful to establish a
health tourism desk at a national level to collect and evaluate data.
9. Explore strategic options to train and retain health personnel in
both the public and private sectors.

Thus, India has the potential to become a “global health

destination”, however, this status will only be meaningful if the
opportunities provided by medical tourism can also be utilised to
improve the quality of services in the public health system in India.

Summary
 The privatisation and 'corporatisation' of health care has created
medical tourism where people from rich nations travel to Third
World countries to obtain medical care, experience and enjoy
the tourism attractions and use other resources.
 Medical tourism will increase export earnings through attracting
foreign exchange into the country, hence lowering fiscal deficit
and assisting the growth of the national economy.
 Some of the challenges that need to be addressed to sustain the
growth of medical tourism are:

o Create inequitable health systems

o Intensify shortages of skilled health professionals

o Raise quality of care and accreditation issues

o Promote unregulated growth of the private sector

o Increase cost of medical treatment

o Raise medical liability issues

Topic 11: Quality Standards in Medical Tourism

1. Objective
At the end of this chapter the student will be able to:

 Explain the role of quality in medical tourism

 Describe the importance of maintaining quality in healthcare tourism
 Explain the role of various international and national accreditation agencies in
maintaining healthcare quality

Introduction
Medical tourism is a growing sector in India. India’s medical tourism
sector is expected to experience an annual growth rate of 30%,
making it a Rs. 9,500-crore industry by 2015. Estimates of the value
of medical tourism to India go as high as $2 billion a year by 2012.

Advantages for medical tourists include reduced costs, the

availability of latest medical technologies and a growing compliance
on international quality standards, as well as the fact that foreigners
are less likely to face language barriers in India. The Indian
government is taking steps to address infrastructure issues that
hinder the country's growth in medical tourism.

Most estimates claim treatment costs in India start at around a tenth

of the price of comparable treatment in America or Britain. The most
popular treatments sought in India by medical tourists are
alternative medicine, bone-marrow transplant, cardiac bypass, eye
surgery and hip replacement. India is known in particular for heart
surgery, hip resurfacing and other areas of advanced medicine.

India is quickly becoming a hub for medical tourists seeking quality

healthcare at an affordable cost. Nearly 4,50,000 foreigners sought
medical treatment in India last year with Singapore not too far
behind and Thailand in the lead with over a million medical tourists.
As the Indian healthcare delivery system strives to match
international standards the Indian healthcare industry will be able to
tap into a substantial portion of the medical tourism market. Already
13 Indian hospitals have been accredited by the Joint Commission
International (JCI). Accreditation and compliance with quality
expectations are important since they provide tourists with
confidence that the services are meeting international standards.
Reduced costs, access to the latest medical technology, growing
compliance to international quality standards and ease of
communication all work towards India’s advantage.

Table: 1 Costs

“Patient Beyond Border” by Josef Woodman. The table used in this

book is available from ABILITY Magazine at
[Link] Note: Costs are for
surgery, including hospital stay only.

Costs assumptions taken for India (20%); Malaysia (25%); Thailand

(30%); Singapore (35%).

It is not uncommon to see citizens of other nations seek high-quality

medical care in the US over the past several decades; however, in
recent times the pattern seems to be reversing. As healthcare costs
in the US are rising, price sensitivity is soaring and people are
looking at medical value travel as a viable alternative option. In the
past, the growth potential of the medical travel industry in India has
been hindered by capacity and infrastructure constraints but that
situation is now changing with strong economic progress in India as
well as in other developing nations.

With more and more hospitals receiving JCI accreditations outside

the US, concerns about safety and quality of care are becoming less
of an issue for those choosing to travel for medical treatment at an
affordable cost. The combined cost of travel and treatment in India
is still a fraction of the amount spent on just medical treatment
alone in many western countries.

In order to attract foreign patients, many Indian hospitals are

promoting their international quality of healthcare delivery by turning
to international accreditation agencies to standardise their protocols
and obtain the required approvals on safety and quality of care.

Increased access to report cards about provider safety and

effectiveness, and patient satisfaction scores for hospitals and
physicians have helped to fuel growing consumer and employer
awareness of safety and quality differences. Traditionally, academic
medical centers (AMCs) have been viewed as “the best,” but these
data reflect comparable performance in community-based settings
for certain services. AMCs have developed highly specialised
Centers of Excellence programs to attract patients from around the
world. Not to be outdone, community-based hospitals have
collaborated with their physicians to develop centers for sports
medicine, heart care, cancer care, and other specialties to compete
for patients across state lines and national borders. In both cases,
strategic positioning has focused on continuity of care and uniquely
packaged price, quality and service features.

Receiving safe and quality care is the primary issue for medical
tourists traveling to another country for treatment. Outbound
medical tourism sponsors are responding to consumers’ safety and
quality expectations, and typically tout these program attributes:

 U.S.-trained physicians and care teams

 Use of clinical information technologies
 Use of evidence-based clinical guidelines
 Affiliations with reputable, top-tier U.S. provider
organisations
  Coordination of pre- and post-discharge care
 Provision for adverse events requiring services unavailable
in the facility
 Certification for safety and quality by the Joint Commission
International or others.

Maintaining High Quality Services In The MT Industry

Safety and Quality Standards

The challenges of seeking care in another country are significant

and require careful consideration. Although some medical tourism
firms tout relaxing destinations and amenities, high quality care and
patient safety must always be the top priorities. 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 healthcare organisation around the
world. Healthcare facilities still struggle to create the systems that
achieve effective care, produce the desired results, and reduce the
risk of unwanted outcomes.

Because standards of care may vary widely from one healthcare

facility to another and from one country to another, it is important to
look for assurances that a healthcare organisation has publicly
committed to 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.

One of the primary concerns for health travelers is whether foreign

providers can offer the same high-quality medical care they receive
in their country of origin.

This growing demand for foreign healthcare providers has prompted

the Joint Commission on Accreditation of Healthcare Organisations
(JCAHO), the best-known healthcare accreditation group in the USA,
to form an international offshoot known as the Joint Commission
International (JCI).
The Joint Commission International (JCI) was launched by the Joint
Commission in 1999 after a growing demand for a resource to
effectively evaluate quality and safety.

There are over 120 hospitals worldwide that are accredited through
the JCI. JCI offers accreditation for hospitals, ambulatory care
facilities, clinical laboratories, care continuum services, medical
transport organisations; and certification in disease- or condition-
specific care for a variety of healthcare programs, including primary
stroke, maternal and well child care, chronic kidney disease,
HIV/AIDS, oncology care, cardiac disease, and diabetes care.

While JCI standards are the same across all countries, JCI
accreditation is designed to accommodate specific legal, religious
and cultural factors within a country. As with Joint Commission
accreditation in the United States, facilities accredited by JCI must
constantly strive for and demonstrate improvement in patient care
performance and reduced risk.

Several other organisations, such as the International Society for

Quality in Healthcare (ISQUA), the National Committee for Quality
Assurance (NCQA), the International Organisation for
Standardisation (ISO), and the European Society for Quality in
Healthcare (ESQH), have taken steps to ensure that medical tourism
facilities provide the highest-quality clinical care (Figure 1).

In 1999, the JCI began surveying and accrediting hospitals and

healthcare facilities outside of the USA. There are now over 220
accredited hospitals worldwide and most are providing quality
services for the medical tourism industry.

Aside from the JCI, there are alternative non-profit groups providing
accreditation for healthcare organisations in the USA. These include
but are not limited to:

Community Health Accreditation Program (CHAP) – The first

accrediting body in the US that provides assessments for
community-based healthcare organisations.

Accreditation Commission for Healthcare, Inc (ACHC) – Was

created by home care providers as an accreditation organisation
that caters to small health institutions.
The Compliance Team, Inc – Is known for their Exemplary
Provider Program.
They are an accrediting body for Durable Medical Equipment (DME).

Healthcare Quality Association on Accreditation (HQAA)

– Another accreditation body working with durable medical
equipment (DME).

National Committee for Quality Assurance (NCQA) – Drives

improvement in the health care system through the Healthcare
Effectiveness Data and Information Set (HEDIS) which is used by
90% of health plans in the USA.

Non-US Accreditation Organizations

Aside from the accreditation bodies based in the USA, there are a
number of international accreditation organizations in the medical
tourism industry that are based abroad. These organizations
perform a similar international role as the JCI, providing
accreditation to international or regional health providers.

Accreditation Canada - Formerly known as the Canadian Council

on Health Services Accreditation (CCHSA) - focuses in improving
patient safety.

Trent Accreditation Scheme (TAS) – A UK-based non-profit

accreditation organization that performs surveying and accrediting
healthcare providers in the UK and around the world.

The Australian Council on Healthcare Standards (ACHS) – The

leading health care and accreditation organization in Australia. It
features the Evaluation and Quality Improvement Program (EQuIP)
and acts as a consultant for several countries.

International Society for Quality in Health Care (ISQua)

– With members from over 70 countries, ISQua has board members
from North America, Europe and Asia-Pacific regions.

European Society for Quality in Healthcare (ESQH) – Is

dedicated to improving the quality of healthcare in Europe. It
consists of 19 member countries, all of which are National Societies
for Quality in Healthcare in their respective countries.
The Society for International Healthcare Accreditation
(SOFIHA) – Is a group formed by providers of international
healthcare accreditation. This forum is where they discuss and share
ideas geared towards developing high-quality accreditation of
medical facilities worldwide.

The International Organization for Standardization (ISO) – Is

an international body formed by various national standards
organizations. In the healthcare industry, ISO provides a framework
in the design and improvement of quality management systems for
healthcare providers.

Figure 1: Safety, Quality and Accreditation Issues Needed to be Asked by the Consumer

Accreditation is particularly important because it can give

consumers and employers a level of confidence that the services
provided are comparable to those available in the U.S., particularly if
accompanied by an affiliation with a reputable, U.S. teaching
hospital. As a result, many well-known AMCs have formed
international partnerships to support offshore tourism ventures and
provide a variety of services, such as:

 Clinical guidelines and order sets

 Care plans for patients to facilitate self-care and adherence
 Electronic medical records and clinical information
technologies
 Outcome measurement and reporting
 Root-cause analysis for sentinel events and error reporting
 Physician and nurse recruitment and training
 Patient satisfaction surveys and reporting
 Medical and professional education
 Purchasing programs for diagnostics and prescription drugs
 Data warehousing and performance reporting.

The legal frameworks used in collaborations between U.S.-based

provider organisations and host outbound medical tourism programs
vary widely. Some focus on work-for-hire for some/all of the services
above; others are equity relationships. The framework in Figure 2
reflects the variety of structures that might be considered.

Care coordination for patients returning home is another dimension

of quality that is central to a host organisation’s performance. Many
U.S based opponents to medical tourism worry that patients who
receive treatment abroad do not receive proper follow-up care when
they return to their home country.

As a result, care plans that facilitate the handoff from overseas

providers to providers at the patient’s home are critical, since
domestic providers are often hesitant to take on complicated and
open cases from unknown providers – let alone care from a foreign
one.

A final issue related to quality is the liability. Although medical

tourism offers significant cost savings, it comes with increased risk
to consumers. If anything were to go wrong during a procedure in a
foreign country, the consumer has to work through the host
country’s legal system.
This can be difficult and burdensome if the consumer lives far away
from the place s/ he received treatment. Additionally, many of the
larger health insurance providers have not yet embraced medical
tourism because they are worried about potential lawsuits linked to
bad outcomes. As medical tourism increases, insurers must find
ways to cope with consumers who look to them for liability.

Figure 2: Collaboration Framework Options and Considerations

Regional Accreditation Bodies

Accreditation Bodies in India – NABH

 Launched in 2005, NABH is a constituent board of Quality
Council of India, set up to establish and operate the
accreditation programme for healthcare organisations in
India.
  NABH has standards specific to the Indian healthcare
setting, major aspects being the assurance of uniform
access, assessment, care of patients and protection of
patient’s rights.

NABH accredited Hospitals

 B.M. Birla Heart Research Centre, Kolkata.

 MIMS Hospital, Calicut.
 Max Super- Speciality Hospital, New Delhi.
 Max Devki Devi Heart and Vascular Institute, New Delhi.
 Kerala Institute of Medical Sciences, Thiruvananthapuram.
 Moolchand Medcity, New Delhi.


The Malaysian Society for Quality in Health (MSQH)

The Malaysian Society for Quality in Health is a voluntary non-profit

organisation which fulfills accreditations for healthcare centers in
Malaysia. MSHQ sets its own standards for accreditation which is
based on organisation and management of the hospital,
management of human resource in within the organisation, the
hospital’s policies and procedure, facilities and equipments in the
hospital and quality improvement measures taken up by the
company. The organisation makes continuous quality checks with
regard to medical care in order to ensure safety of patients who
seek medical services in these accredited hospitals.

Thailand

Thailand has Institute of Hospital Quality Improvement &

Accreditation

Thailand has Institute of Hospital Quality Improvement &

Accreditation as its accreditation providing organisation to ensure
quality standards among Thailand’s medical institutions.

Singapore

Singapore Accreditation Council (SAC)

Singapore Accreditation Council (SAC) was formed in 1996 and it
represents Singapore’s regional accreditation organisation. SAC's
primary function is to accredit conformity assessment services such as
testing, calibration, inspection and certification.

Health Sciences Authority (HSA)

Health Sciences Authority is a multidisciplinary agency in health

sciences sector which was formed as a statutory board of the
Ministry of Health on 1st April, 2001. It has since then been working
towards protection and advancement of national health and safety.

Accreditations to health service centers serve as a benchmark in

assuring the quality of service, and as such helps patients embrace
medical tourism without any doubts about the quality of service in
hospitals outside their homelands.

Other organisations providing contributions to quality

practices include:

HealthCare Tourism International, the first US-based non-profit

to accredit the non-clinical aspects of health tourism, such as
language issues, business practices, and false or misleading
advertising prevention. The group provides accreditation for all
major groups involved in the health tourism industry including
hotels, recovery facilities, and medical tourism booking agencies.

The United Kingdom Accreditation Forum (UKAF) is an

established network of accreditation organisations with the intention
of sharing experience good practice and new ideas around the
methodology for accreditation programmes, covering issues such as
developing healthcare quality standards, implementation of
standards within healthcare organisations, assessment by peer
review and exploration of the peer review techniques to include the
recruitment, training, monitoring and evaluation of peer reviewers
and the mechanisms for awards of accredited status to
organisations.

The International Medical Travel Association, (IMTA, based

in Singapore), is a nonprofit association formed to help address
quality standards, liability issues, continuity of care, and other
issues.

Medical Tourism Association (MTA) is a nonprofit association

focusing on transparency in quality and pricing.

The Medical Tourism Association, a nonprofit organisation, is among

the first in the medical tourism industry to promote standards and
guidelines for quality of care around the world. The Medical Tourism
Association (MTA) offers consumers from around the world the
opportunity to become accredited and certified members of the
Association, but in order to do so they must be evaluated and
certified as providers of excellent quality healthcare. The
certification process defined by the Medical Tourism Association is a
thorough, extensively detailed and stringent process that takes
between 3 to 4 months for a facility to complete. Quality of care is
essential to the medical tourism industry, and offers consumers the
peace of mind that comes with knowing a facility is well staffed,
educated, expertly trained and experienced in a number of
procedures, including but not limited to obesity weight loss
procedures, cardiac care, cancer treatments, orthopedic surgeries in
orthopedic procedures and more.

Facilities certified and having completed accreditation guidelines by

the Medical Tourism Association reduce the potential of risks and
errors, establish and promote patient rights, adhere to religious or
cultural requirements for international travelers, set facilities and
physicians apart from competitors and promote interaction with
domestic and international insurance companies, to name a few.

The future of healthcare is in medical tourism, and the Medical

Tourism Association is making sure that consumers can feel
comfortable and confident regarding their medical care, regardless
of destination.

Accreditation In Ayurveda
The elevation of ‘Ayurveda’ as a USP of Kerala Tourism has brought
a substantial increase in the ayurveda massage centres in and
around all the major tourist destinations in the State. Most of these
operate according to their terms and often flout safety and health
regulations. To forestall any such misuse and maintain a uniformity
of practice Government of Kerala has brought out a scheme for the
Approval of Ayurveda Centres. According to this order, a uniform
approval is given to all the centers fulfilling the conditions
prescribed, irrespective of its class in quality. It is now felt that a
classification of the centres are necessary to differentiate in the
level of quality of facilities and services provided in the approved
ayurveda centres.

Under these circumstances, Department of Tourism, Government of

Kerala has worked out a revised scheme for the classification of the
ayurveda centres in order to promote tourism in the State.

The centres will be classified into Green Leaf and Olive Leaf
categories based on quality standards maintained by the ayurveda
centre as prescribed in the order.

Incentives to classified ayurveda centres

Only the ayurveda centres, which are classified/approved by

Department of Tourism, will be eligible for claiming 10% state
investment subsidy or electric tariff concession offered by
Department of Tourism, Government of Kerala. Only these centres
will be considered for giving publicity and promotion through print
and electronic media by the Department.

International Certification Status Of Medical Tourism

Providers
Destination countries for medical travelers, realising the impact of
the medical tourism business in the economies of their respective
countries, strive to provide the highest quality at the lowest possible
cost. These countries are openly marketing medical tourism, with
governments supporting these efforts by providing better facilities
and seeking international accreditation.

Part of these efforts includes hiring or training physicians with

international credentials such as, professionals who train and are board
certified in the USA, Australia, Canada and Europe. For example:
India – Apollo Hospitals is the largest healthcare provider and the
first JCI-certified hospital in India. The Apollo Group is also tied with
Johns Hopkins Medicine International on studies regarding heart
diseases. On top of this, the Indian Healthcare Federation provides
accreditation standards for its local providers. Another provider,
Wockhardt, is affiliated with the Harvard Medical School.

Singapore – This country provides state-of-the-art hospitals, three

of which are accredited by the JCI. The International Medical Centre
which is also affiliated with Johns Hopkins International is the most
notable.

Panama – With several Panamanian physicians trained and certified

in the United States, Panama's top hospitals are comparable to the
US. Foremost is the Punta Pacifica Hospital which is affiliated with
Johns Hopkins International.

Thailand – There are over 1 million medical tourists going to

Thailand each year. The front-runner for Thailand's medical tourism
industry is Bumrungrad International Hospital in Bangkok. They are
located in a modern hospital building that complies with US
standards, and an American-managed medical staff that includes
200 US board-certified doctors and surgeons. The rest of the staff
members are licensed in Australia, Europe and Japan.

There are other foreign hospitals that are owned, managed or

affiliated with American hospitals, healthcare providers and
prestigious universities. An example is the Cleveland Clinic which
owns and manages several facilities in other countries like Canada,
Austria and the United Arab Emirates. The International Hospital
Group which is based in Dallas, builds and operates US-standard
hospitals in Mexico.

Qualification of Doctors and Surgeons in Medical Tourism

Destinations

Just as many doctors in the USA undergo part of their medical

training abroad, many physicians from other countries have also
trained and received board-certification in the United States. Foreign
hospitals boast of their US and/or internationally certified medical
staff. This can boost their image in the medical tourism industry.
Many of these physicians have fellowships with American medical
societies and have specialty certification from an American medical
board.

The golden standard for certification for the medical profession in

the USA is provided by the American Board of Medical Specialties
(ABMS).

This is the umbrella organisation for 24 nationally approved medical

specialty boards. The coveted Gold Star is given by the ABMS to
certified local and international physicians to demonstrate their
expertise in their specialty fields. Certifications by the ABMS and its
Member Boards are widely referenced by healthcare organisations,
law firms and insurance companies. These specialty boards include
the following certification bodies:

 American Board of Allergy and Immunology

 American Board of Anesthesiology
 American Board of Colon and Rectal Surgery
 American Board of Dermatology
 American Board of Emergency Medicine
 American Board of Family Medicine
 American Board of Internal Medicine
 American Board of Medical Genetics
 American Board of Neurological Surgery
 American Board of Nuclear Medicine
 American Board of Obstetrics and Gynecology
 American Board of Ophthalmology
 American Board of Orthopaedic Surgery
 American Board of Otolaryngology
 American Board of Pathology
 American Board of Physical Medicine and Rehabilitation
 American Board of Plastic Surgery
 American Board of Preventive Medicine
 American Board of Psychiatry and Neurology
 American Board of Radiology
 American Board of Surgery
 American Board of Thoracic Surgery

In the UK, the prominent professional medical association is the

British Medical Association (BMA). However, certification is provided
by the General Medical Council (GMC), which is responsible for
controlling the certification and licenses of doctors and surgeons.
The GMC also liaises with medical associations and certification
bodies from other countries, particularly medical tourism industry
providers. The result is a mutual recognition of physician
qualifications.

In Europe, the European Union of Medical Specialists (UEMS) is

responsible for controlling the certification and licenses of doctors
and surgeons. The GMC also liaises with medical associations and
certification bodies from other countries, particularly medical
tourism industry providers. The result is a mutual recognition of
physician qualifications. With over 1.4 million certified medical
specialists represented by the UEMS, they aim to standardise the
laws and practices of the National Medical Associations from
member countries.

Facilitating Seamless Coordination Of MT

The decision-making process for patients considering treatment
abroad can be daunting.
Figure 3 reflects the typical decisions and actions that take place.
Figure 3: Pre- and Post-procedure Decision-making Process

Because of this complexity, many patients look to their health plan

or employer to assist in navigating the process. In some cases,
these organisations hire medical facilitators to seamlessly
coordinate outbound medical tourism programs. Medical Tourism
Facilitators have played an important role in promoting the growth
of medical tourism, and for many medical tourism patients,
represent their first face to face contact with the concept of medical
tourism.

Medical facilitators are companies that guide the use of medical

tourism for patients and providers. Many patients find using
facilitators to be more convenient and expedient than looking for a
program on their own. Facilitators have experience in the medical
tourism process and are able to address any concerns or questions
that patients might have. They often provide assistance with
logistics and travel arrangements. Patients may even be able to get
lower rates from medical facilitators than directly from clinical
programs abroad.

Medical facilitators can be divided into four groups: (Figure

4)

 Hotel Groups, such as the ITC-WelcomGroup in India, have

expanded their service line to act as a facilitator between
the patient and the provider.
 Travel Agencies, such as Commonwealth Travel in
Singapore, have tour plans for medical travelers and utilise
their experience to organise logistics.
 Medical Travel Planners, such as MedRetreat, Planet
Hospital, Global Choice Healthcare, and BridgeHealth
International, act as patient representatives in finding
treatment abroad.
 Provider Groups, such as Bumrungrad in Thailand and
Apollo in India, have dedicated clinical programs solely for
international patients.

Advantages Of Using A Medical Tourism Facilitator

One-stop Medical Tourism shopping: The convenience of being
able to choose and access information about a variety of
destinations, hospitals, procedures, and services. Users can come to
a medical tourism facilitator’s website and request a price estimate
for a particular procedure from several different hospitals or clinics,
and then choose which provider better serves their needs and
budget. In addition, once you have made a decision on where to
travel, the medical tourism facilitator can usually take care of all
your travel logistics such as flights, lodging, and transportation.

Established relationships with international

providers: Medical Tourism Facilitators, at least in theory, have
already done the groundwork to make sure your chosen hospital
and doctor are accredited and safe to work with. The best case
scenario is that they have visited your chosen hospital and already
have a system in place to make your Medical Tourism Trip process is
a smooth one.
Figure 4: Medical Tourism Service Facilitator

Convenient transfer of medical information: Most medical

tourism facilitators have a mechanism in place for quickly
transferring your medical information including large files such as
CT’s and MRI’s.

Language and culture barriers are usually not an

issue: Contacting some international hospitals can be challenging
due to time zone differences, language barriers, and cultural
differences. As shown above, medical tourism facilitators already
have the right contacts and a Medical Tourism Trip/medical tourism
process in place with your international hospital. Additionally, as
most medical tourism facilitators are located in North America, you
will be dealing with people who speak your language and have a
better understanding of the obstacles you face in order to get you
from point A to point B.
Summary
 It is important to look for assurances that a health care
organisation has publicly committed to safe, quality patient
care.
 Community Health Accreditation Program (CHAP) is the first
accrediting body in the US that provides assessments for
community based healthcare organisations.
 Some of the non-USA accreditation organisations are:

o Accreditation Canada

o Trent Accreditation Scheme (TAS)

o The Australian Council on Healthcare Standards (ACHS) –

o International Society for Quality in Health Care (ISQua)

o European Society for Quality in Healthcare (ESQH)

o The Society for International Healthcare Accreditation

(SOFIHA)

o The International Organisation for Standardization (ISO)

 Medical facilitators can be divided into four groups:

o Hotel Groups

o Travel Agencies

o Medical Travel Planners

o Provider Groups
Topic 12: MT-Ethical, Legal & Social Concerns
1. Objective

At the end of this chapter the student will be able to:

 List the various ethical, social and legal issues in medical tourism.
 Describe the various ethical concerns like surrogate motherhood, stem cell
therapy and other issues in context of medical tourism.

Background And Context

In contemporary times medical tourism occurs both across and
between both richer and poorer countries and is motivated by a
variety of elements such as the cost of treatment; quality of
services; length of waiting time; and availability of complementary
and alternative medicine. One of the first countries to actively
promote this new form of medical tourism was Cuba. In the early
1990s the Cuban government advertised “sun and surgery”
packages including dental, cardiac, organ transplant and cosmetic
procedures in conjunction with spa or “wellness adventures”.
Goodrich & Goodrich (1987) conducted one of the first academic
studies of health tourism, developing an early definition of the term
as:

…the attempt on the part of a tourist facility (eg hotel) or

destination (eg Baden, Switzerland) to attract tourists by
deliberately promoting its health-care facilities, in addition to its
regular tourist amenities. (Goodrich & Goodrich, 1987:217)

In subsequent years, the labels health tourism, healthcare tourism

and medical tourism have been used broadly and somewhat
interchangeably, with the more recent addition of a number of other
descriptors.
A tentative and relatively broad definition of medical tourism offered
is the movement of individuals from one location to another
primarily in order to seek medical services.

Although it has been established that health-related travel is not a

new phenomena, the global direction of patient travel is purported
to be shifting away from individuals traveling from poor countries to
rich destination countries in order to access health services
unavailable at home, towards that of individuals from rich countries
traveling to poorer nations (de Arellano, 2007; Whittaker, 2008).

Critical theorists have questioned the basis of market-led health

systems, where a range of social scientists have examined global
shifts towards the commercialisation of healthcare and the
consequent mounting frictions between the competing principles of
healthcare as a commodity or a right. However, commercialisation
within the health sector is not a new phenomenon, where there has
been a historical precedence internationally with cycles of
commercial health expansion, opposition and then retreat over time
(Mackintosh 2006). Waitzkin (2000:7) has argued that the
commercialisation of healthcare is a fait accompli in context of the
capitalist system where “from the standpoint of private profit, there
is no reason that corporations should view medicine differently from
other goods and services”.

Reflecting upon the main claims in the emerging literature on

medical tourism, much is framed around the posited economic
benefits for the “destination” country and the prospects of medical
tourism in driving economic development. This can be illustrated by
a study produced by Bookman & Bookman (2007), which is also the
only academic book that has been published on medical tourism to
date. This study predominantly examines medical tourism’s
potential for promoting economic development within Third World
countries. The argued benefits are generally framed by three central
claims. Firstly it is contended that it will increase export earnings
through attracting foreign exchange into the country, hence
lowering fiscal deficit and assisting the growth of the national
economy. Secondly, it is argued that the combination of increased
medical technologies and the growth of health specialists and
greater levels of expertise will generally raise the standards of
healthcare across the country through competitive market practices,
which will eventually translate to an increase of the standards in the
public sector. (Bookman & Bookman, 2007) Although in general, the
media, government and private sectors are maintaining medical
tourism will improve the public healthcare system and health status
of the population, rhetoric surrounding the methods in how this will
be achieved is either absent or employs the widely critiqued notion
of the “trickle-down” concept. The general assertion made is that
economic growth derived from medical tourists will be siphoned
back into hospitals, improving the technology and equipment, which
will benefit the population at large. Thirdly, it is argued that the
economic growth medical tourism could generate would result in an
overall increase of national income, thus creating equity in access
through allowing more of the population access to private care.
(Henderson, 2004; Turner, 2007). However, most of doctors from
public sector shared their concerns about the poor and the
accessibility of public health services for them. And most of them
believed that growth of Medical Tourism in no way is going to
improve the situation in the public health sector as envisioned by
few, of trickle-down effect

Despite these arguments, it has been widely acknowledged that

many economic development programs implemented in the past
have been extremely detrimental to different sectors of the
population through the disregard for their social effects.

Regardless of this acceptance, there are many elements of medical

tourism, specifically when viewed as a facilitator of economic
development, which echoes past development outlooks. Firstly, the
high-tech nature of most medical tourism brings it association with
modernism, placing it in prominently and positively in the public
eye, serving as an example of the of a nation’s “development”. This
is argued to draw attention away from faltering public health
systems and public health via a distortion of priorities. (Bookman &
Bookman, 2007:176) Secondly, government promotion, concessions
and incentives directed towards the medical tourism industry are
challenged in contexts where public health expenditure is
consistently reduced (Chacko, 2005; Lautier, 2008).

Another of the most widely employed criticisms refers to the further

entrenchment of a two-tiered health system, where it could cause or
exacerbate a dual market structure consisting of: (1) a high quality
and high priced sector catering to foreigners and affluent nationals;
(2) a resource constrained and lower quality sector catering to the
majority of the local population (Chanda, 2001; de Arellano, 2007;
Whittaker, 2007). Medical tourism may raise broader ethical issues
for the countries in which it is promoted. First, local populations can
rarely afford access to the high-quality services set up for tourists,
even with the discount system available in India Whether the
citizens of India are receiving "compromised care" because
healthcare resources are being diverted to medical travelers or
medical tourists are perhaps the toughest ethical issue for the
medical travel industry.

If anything, health tourism is decreasing equity in access to

healthcare for local populations, creating a two-tiered system
widening the gap between the ‘have’ and ‘have-nots’. The ‘external
brain drain’ is being replaced by ‘internal brain drain’ where
professionals move from public to private hospitals in the same
country, attracted by money. Nurses and physicians could easily be
further diverted away from the home population by catering to
better paying foreign patients. Although the flows of health workers
across and within national borders is yet difficult to quantify due to a
lack of monitoring, a representative of the World Health
Organisation has contended that from “initial observations” medical
tourism appears to encourage both movements (World Health
Organisation (WHO), 2007), but to what ratio this ‘double
movement’ of health workers is occurring remains unclear.

In the US, many insurance policies promote ‘organ tourism’ in the

face of donor organ shortages and high treatment costs, introducing
significant ethical dilemmas. What about residents awaiting organ
transplant in developing countries – do they go without whilst the
affluent take the organs? Australia and New Zealand have tackled
this by having two waiting lists, allocating organs to native residents
first; after all, guests should not have equal access to organs. The
impact of long-distance air travel associated with health tourism
upon the environment goes without saying Immigrants to
industrialised countries are anything but health tourists, whereas
the growing health tourism industry in developing countries is
fraught with ethical quandaries.
Restricting access to healthcare to immigrants in industrialised
countries costs more long-term, poses significant public health
problems, and infringes human rights. If an illness is not prevented
and treated among these immigrants, the whole community will
suffer. Immigrants often face language and cultural barriers, the
stress of emigration, and poverty in a new land; further inequalities
in access to healthcare means their health suffers as a result.

Stem Cell Therapy

Stem-cell therapies are emerging as a growing area of medical
tourism, even while research is still in its early stages. The trend is
causing concern among experts.

Stem-cell experts are worried that some doctors in developing

countries are treating patients with adult stem cells without waiting
for clinical trials to validate the safety of using them for health
problems.

In treatments using adult stem cells, the cells are injected into the
blood, the lumbar region, or damaged tissue. The only treatments
using adult stem cells that are proven by trials are for blood
disorders, bone marrow transplantation, and rare immune
deficiencies. Current clinical trials are mostly focused on heart
disease.

The International Society for Stem Cell Research (ISSCR), in late

2008, released guidelines for patients who are seeking stem-cell
treatments from unlicensed doctors overseas in increasing numbers.
The guidelines insist that all treatments must be expertly evaluated
with independent oversight. They also advocate for an informed
consent process to provide patients with information about stem-
cell-based treatments, and transparency in reporting of trial results.

Surrogate Motherhood
Another area of concern in medical tourism is Surrogate
motherhood. Surrogate motherhood is the process whereby a
woman agrees to carry a child for a childless couple and then to
deliver the baby for them nine months later, usually in return for
some monetary compensation.

There are several forms of this, all made possible by advances in

human fertility technology, most notably in vitro fertilisation (IVF).
Typically, the egg from the biological “mother” is fertilised by the
father’s sperm in a test tube, and the resulting embryo is then
transferred to the womb of the surrogate mother. It is still very
much a grey area in ethical terms.

The legal issues in the United States are complicated, having to do

with that the surrogate mother still has legal rights to that child until
they sign over their parental rights at the time of the delivery. Of
course, and there’s the factor of costs. For some couples in the
United States surrogacy can reach up to $80,000.”

Different societies have responded to this possibility in different

ways. Several countries, such as Sweden, Spain, France, and
Germany, have banned the possibility of surrogate motherhood
after it was rejected by voter referendum. Even in countries where it
is allowed, there are restrictions. In Canada, payments are banned
in surrogacy cases, to prevent commercialisation, and in the United
Kingdom only some costs can be provided for. In developing
countries that do allow it, such as Argentina and South Africa, there
are stringent norms mandated for the process, including case-by-
case reviews and monitoring by independent ethics committees.

Reasons for Concern

There are many reasons for concern. Quite apart from the purely
ethical reasons, the most obvious problems related to the risks
involved for the surrogate mother. These include both the physical
risks to health and the psychological and emotional damage that
can be caused by having to part with the child after birth.

The physical risks are obviously greater in the context of less

developed countries where complications in pregnancy and
childbirth are more common and health services are less advanced.
They are also more likely among poor women, whose general health
and nutrition conditions may make them more vulnerable. It is
precisely among women of lower socio-economic status that
mortality and morbidity associated with pregnancy are higher, and
yet they are the group from which the potential surrogate mothers
are drawn.

But even the emotional concerns should not be underestimated.

Child-bearing is not just like any other work activity –– it is a difficult,
complicated and very emotional process, which completely takes
over the life of the mother, and also involves hormonal changes that
generate feelings. There is a strong possibility that the expectant
mother can develop emotions that make the eventual giving away
of the child extremely difficult. This is actually recognised officially
in several places. In Britain and in some states of the USA, for
example, a surrogate mother is given the opportunity for some time
after bearing the child, to stake a claim for custody. There have
been several instances of prolonged and bitter custody battles as a
result.

Indifferent Government

In India, there appears to be less governmental concern with any

such issues, whether they relate to ethical concerns, or health of the
surrogate mothers, or emotional consequences. In fact, there are
currently no laws regulating the fertility industry, even though there
have been many demands for such regulation. There are only some
non-binding guidelines issued by the Indian Council for Medical
Research, which do not have to be adhered to either by doctors and
medical institutions or by those seeking to rent the wombs of Indian
women.

As a result, there are no such legal or other constraints in the

process of paid surrogate motherhood, which is even actively
encouraged in some states. And of course, all this is particularly
cheap in India, where there are many millions of poor women with
few and declining livelihood opportunities, who will see this as a way
of making some money.

IVF techniques now allow for a wider range of possibilities, including

some which were previously unthinkable, such as using frozen
embryos from dead parents.
But in particular, it has allowed for the development of commercial
surrogacy, for a pecuniary motive. Of course, this more recent
development is not simply, as result of technology – it reflects the
spread of commercialisation to this most fundamental aspect of life.

But there are other advantages too, especially the relative ease and
lack of regulation which effectively allow couples to shop around for
the best terms and easiest delivery process. Instead of controls, our
laws actually promote surrogacy. For example, the current laws
require the surrogate mother in India to sign away her rights to the
baby as soon as she has delivered it. Further, the implanting of
embryos into the womb of a surrogate mother is permitted as many
as five times, compared to a maximum of two times in most other
countries.

The poor – in India and elsewhere – are often reduced to selling the
use of their bodies as part of desperate survival strategies for
themselves and their households. The sale of organs such as
kidneys, by those in need, has been well documented and continues
to create outrage. For some reason, there is less social
consternation about surrogate motherhood. Instead, there is even
some amount of satisfaction among some health professionals that
they have managed to find a new avenue for earning foreign
exchange and employing some of our evidently underemployed
women.

Reproductive tourism is potentially a huge business: ICMR estimates

that it could earn $6 billion in a few years. Also, as more and more
poor women are drawn into it, they receive incomes much larger
than they could access within their existing livelihood and with their
levels of skill.

Other topics—such as medical travel's influence on the continuum of

care, destination hospitals providing services that are illegal in home
countries and malpractice mitigation are some other ethical issues.

Legal issues: By traveling outside their home country for medical

care, medical tourists may encounter unfamiliar ethical and legal
issues. The limited nature of litigation in non-US countries is one
reason for the lower cost of care overseas. 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. Should problems arise, patients might not be
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 indemnity. However new insurance products
are available that protect the patient should an alleged medical
malpractice occur overseas.

Summary
 Stem-cell therapies are emerging as a growing area of medical tourism, even while
research is still in its early stages. The trend is causing concern among experts.
 Surrogate motherhood is the process whereby a woman agrees to carry a child for
a childless couple and then to deliver the baby for them nine months later,
usually in return for some monetary compensation.
Topic 13: Medical Tourism-Issues & Challenges
1. Objective

At the end of this chapter the student will be able to:

 Explain the issues and challenges of medical tourism.

 Describe the opportunities for health systems in medical
tourism.

Introduction

Where does India Healthcare Industry Stand?

India has a wide network of public and private hospitals; most of the
healthcare services are provided by the private sector. Public sector
institutions are run by the Central or State government bodies,
whereas private hospitals are managed by trusts as a profit or not-
for-profit organisation. In the recent past, there have been major
changes in healthcare delivery. India is gradually moving from
conventional standalone set-ups to hospitals chains with well-
integrated networks. There is increasing penetration of Information
Technology (IT) applications in healthcare institution. An IT
application further enhances the quality of care and helps to provide
one-stop-solution to the patient’s need. India is also at the forefront
to adopt innovative solutions such as usage of telemedicine
services. There is a continuous increase in the number of healthcare
institutions offering telemedicine services. Telemedicine is in
infancy, but it is making inroads at a fast pace and India is expected
to emerge as a country with a high penetration rate for
telemedicine.

Healthcare delivery in India-a snapshot

India needs to expand its healthcare facilities to cater to its one

billion plus population. India has around 1,80,000 hospitals out of
which 1,60,000 are primary healthcare centres. India has a three-
tier system. Tier I hospitals provide super speciality healthcare
services, for example, Cardiac surgery, Surgery Tumour Removal,
Organ Transplantation etc. They are located in metros and state
capitals, around 70-80 per cent of tier I hospitals have around 250-
300 beds. Tier II hospitals are general hospitals, which do not
conduct super-specialty surgeries. They are mainly present in State
Capitals and other important cities in each state where there is a
negligible presence of tier I hospitals. Tier II hospitals typically have
a bed strength ranging anywhere between 50-100 beds. Tier III is
generally 5-25 bed hospitals which are more popularly termed as
nursing homes in India. They may have a small ICU with very basic
instruments and a minor OT attached for very basic procedures. In
big cities, they play a primary role in treating patients with minor
ailments, which do not need surgical intervention or advanced care.
Conversely, in small towns they perform the same roles, which tier II
hospitals perform in the bigger towns and cities, namely, to stabilise
patients with serious conditions and then transfer them to tier I
hospitals for advanced treatment. Health services will also have to
cope with an increase in the chronic and lifestyle-related conditions
associated with rising incomes and greater longevity.

In India, 80-85 per cent of the healthcare expenditure is borne by

the patient; 12-15 per cent by the government and a mere 2-3 per
cent by the insurance sector. Due to inadequate support from the
government, the Indian market is completely controlled by the
private sector marking it very price sensitive.

This year, the government’s budgetary allocations to healthcare

have also been increased to 21.9 per cent over the previous year.
The per capita expenditure on healthcare is also on the rise due to
the increase in related diseases. To cater to this demand, both
public and private healthcare facilities are working towards efficient,
affordable and quality healthcare delivery. The private sector is
focussing more on tertiary level healthcare services whereas the
government is concentrating on the root causes through services
towards prevention and eradication.

India has made significant advances as a healthcare destination.

However, there still are several roadblocks to the growth of the
sector in the country.

Healthcare service industry is one of the flourishing sectors of the

Indian economy which is cashing in on the opportunities that
liberalisation of markets around the globe opened. Lifestyle diseases
have emerged from the demanding and hectic pace of life led by
people today. There is thus a need to de-stress and increase
involvement in leisure activities. Increase in awareness to keep
oneself healthy coupled with a rise in the standard of living have led
to increase in demand for quality healthcare services.

According to the General Agreement of Trade in Services (GATS)

definition, “trade in health services occurs via four modes of supply;
these are cross-border delivery of trade, consumption of health
services abroad, commercial presence and movement of health
personnel.” Medical Tourism falls under the category of
consumption of health services abroad. It has evolved through the
coming together of two services hitherto unrelated, i.e., healthcare
and tourism.

Issues and Challenges

The medical tourism market in India is worth US$ 333 million,

growing at 30 percent per annum. Due to the emergence of this
industry in India, massive tasks lie ahead to synergise the resources
of the two sectors. However, there are issues and challenges that
need to be addressed to overcome the roadblocks to facilitate the
growth of this industry in India. The issues that need attention are:

1. Upgradation of basic amenities and hospital infrastructure

2. Co-ordination between the healthcare and tourism sectors

3. Creating a resource pool of highly skilled and cordial manpower

4. Internal Brain Drain

5. Standardisation of services and accreditation of hospitals

6. Increasing visibility of India on the world map

7. The impact on domestic healthcare services

8. Regulatory System

9. Health Equity and Ethics

10. Dependence on foreign clients

11. Technocentric approach to healthcare

12. Portability of Health Insurance

13. Government Leadership

1. Upgradation of Basic Amenities and Hospital Infrastructure

Basic amenities in India are not up to international standards,

especially air connectivity, road links, conveyance services and
Internet connectivity. This gives a poor image of the country to
health travelers, and also raises doubts about the quality of
healthcare facilities. The state of basic amenities in a country has a
considerable impact on the choice of destination for health
travelers. Basic amenities need to be upgraded and made hassle-
free. Travel visa is another critical issue which the Indian
government plans to address by introducing special medical visas
for foreign tourists coming to India for specialised treatment. This
visa will allow the patient to bring along two attendants and will also
enable him to access the finest medical care in the most recognised
hospitals in the country, that specialise in the treatment he is
seeking.

Physical Infrastructure (Investments)

The Indian healthcare delivery market is also making its presence

felt in the global market by providing high-class quality services and
focusing on medical tourism. An estimated 50 per cent of tertiary
level hospitals focus on providing services to the medical tourism
sector. Some big industry players like Apollo, Wockhardt; Max, Fortis
and Manipal. have changed the face of the industry by providing
world-class healthcare facilities. They already have hospital chains
covering all geographic regions of India. Nevertheless, the current
healthcare infrastructure in India is inadequate to meet the future
needs.

An estimated 7.5-9 lakh hospital beds are required by 2012 to meet

the current rate of demand. This infrastructure would need an
investment of approximately US$30-40 million.

The existing infrastructure facilities in private hospitals in India are

considered to be on par with those in the UK and the US. However,
with an annual growth rate of 30 percent, there exists a huge
opportunity to expand the hospital infrastructure. Recognising this,
the government of India through various measures is encouraging
private sector investment in the sector. It has conferred
‘infrastructure’ status for the healthcare industry and allowed
foreign collaboration. In addition, concessions in tax to raise cheaper
long-term funds, reduction in import and custom duties on medical
equipment, increase in depreciation limit and income tax exemption
for the first five years if the hospital has a capacity of hundred beds
or more, have been granted. The concern here is whether
corporates will use these incentives as intended by the state, and
whether they will repay society in equal measure.

2. Co-ordination between the Healthcare and Tourism

Sectors

Co-ordinating the resources and services of two unrelated sectors—

healthcare and tourism—is challenging. Strategic co-ordination
essential between these two sectors can be done through facilitation
by the government. The Indian Healthcare Federation, Medical
Tourism Council of Maharashtra, FICCI, the government of India and
respective state governments are coordinating to promote this
industry. The services of both the healthcare and the tourism sector
are required simultaneously once the patient finalises the hospital
from where he/she wishes to avail of the healthcare services.
Arrangement for passports, visas, airline tickets and conveyance has
to be made. The availability of a doctor, date of surgery, days to be
spent in the hospital and recuperation services have to be
confirmed. All this requires co-operation from both the hospital and
the tour operator. Thus there is a need to train the people of these
two sectors to meet the requirements of this special segment of
tourists. Conferences, an interaction between the two sectors,
knowledge upgradation workshops, coaching for personality
development and investment in information technology are the
ways to strengthen this synergy.

3. Creating a Resource Pool of Highly Skilled and Cordial

Manpower

Indian doctors are well-known abroad for their qualifications and

skills. This is a big advantage for hospitals in India in attracting more
medical tourists. India has the advantage of having advanced life-
saving healthcare services like organ transplants, cardio-vascular
surgery, eye treatment, hip replacement and in-vitro fertilisation.
There are 5,00,000 doctors and 7,37,000 nurses serving in the
Indian healthcare sector and 18,000 persons get qualified as doctors
each year from 170 medical colleges, according to a CII-McKinsey
report. This skilled human resource pool can help to meet the
increasing demand for healthcare services in India. In addition to
hiring and retaining skilled manpower, service expectations of
medical tourists have made it imperative for hospitals to create an
ambiance of well-being and cordiality so that their clients feel
comfortable and well-attended while on treatment. Corporate
hospitals are investing in furnishing their facilities and in training
and development of personnel through seminars and short-term
courses to gear them up to meet the requirement. A major concern
here is about trained medical professionals who go abroad thus
diminishing the service capabilities of hospitals in the country.
Another concern is that more that 50 percent of these doctors are
located in urban hospitals causing a shortfall in the already stressed
public healthcare system affecting the larger public in the long run.
Doctors working in these private hospitals currently contribute to
the public by participating or conducting medical camps and
providing consultancy services through telemedicine to remote
villages. But once they get assigned to foreign tourists, their
continuance in public services may become doubtful.

4. Internal brain drain

An increase in the number of private hospitals, due to rapid
economic growth or an investment in medical travel, can create an
increase in demand for more doctors, which in turn can lead to an
internal brain drain from public health systems to private hospitals.
As private hospitals expand to absorb the increasing number of
medical travelers, they will need more medical and other
professionals. In many cases, the top specialists in corporate
hospitals are senior doctors drawn from the public sector.

This has been observed in many countries where private and public
hospitals coexist. For example, in Thailand, during the period 1988-
1993, rural district hospitals had to function without a single full-
time physician due to internal brain drain. This trend was reversed
immediately after the 1997 Asian financial crisis, when many
doctors who had left the public sector returned to public hospitals
because private hospitals had lost their middle-class clientele.
Presently, this trend has once again reversed.

Another important trend is the urbanisation of healthcare. As part of

the brain drain, more and more health professionals are being
drawn to large urban centres, and within them, to the large
corporate-run specialty institutions. The urban concentration of
healthcare providers is a well-known fact; 59 per cent of India’s
practitioners (73 per cent being allopathic77) are located in cities,
and especially metropolitan ones. In Thailand, in 2006, around 35
per cent of the country’s medical doctors were based in Bangkok.

5. Standardisation in Pricing and Accreditation of Hospitals

The only one quality that Indian health industry lacks in is Health
standards and hygiene. Indian hospitals lack accreditation from the
Joint Commission on Accreditation of Healthcare Organisations
(JCAHO), suffer from a lack of standards in terms of quality and rates
for healthcare procedures, have no gradation system and a far from
perfect insurance sector. In addition, top Indian hospitals have high
infection and mortality rates, and are unwilling to disclose data
regarding these. Accreditation of hospitals in receiving countries is
critical to ensure the quality of care received by patients in
hospitals.
Accreditation by reputed agencies, such as JCI, most commonly
used, the Trent International Accreditation Scheme and ISO,
facilitates sustainable connections with foreign insurance companies
and also assures the patient about the quality of care received.

However, accreditation comes with a cost tag attached and

individual hospitals in some countries in the region may feel that the
costs of the process have an impact on the cost of treatment.
Governments have a role to play by not only putting in place
accreditation mechanisms, but also by working with stakeholders to
reduce costs of such accreditation.

For example, in the Philippines, preparation for the JCI accreditation

process of the Medical City took almost two years. Preparation
included an expensive organisation-wide project that required
comprehensive and intensive systems reviews, re-engineering,
documentation and training.

In the area of accreditation, international cooperation on mutual

recognition of national accreditation standards is also a key process.
Exploring other European or Asian-based hospital accreditation
systems is also important to any attempts to broaden the medical
tourism market, as JCI's principal appeal is to the market in the
United States of America, only one portion of the potential global
clientele.

Apollo group of hospitals which has become the first hospital in India
to get a JCI certification, the gold standard for the US and European
Hospitals. The same has to come to more hospitals of India.

Standardisation in pricing of various surgeries and healthcare

services is required as vast price differences exist across hospitals.
The Indian Healthcare Federation (IHF) has brought in the concept of
‘price banding’ to bring some consistency in the prices of different
therapies and procedures, along with the move to accredit hospitals.
Currently, the ‘price banding’ concept is in the consensus stage;
once all the IHF members approve it, it will be legalised through the
government. Accreditation will be used to negotiate with overseas
health insurance companies to extend their cover to include
treatment in India. Both standardisation in pricing and accreditation
will help Indian hospitals in attracting more medical tourists. Dr.
Naresh Trehan, the director of Escorts Heart Institute and Research
Centre, says “there are 5 crore uninsured people in the US, where
the annual premium for health insurance is as high as $10,000 for a
family of four. Besides, corporates are finding it increasingly difficult
to insure their employees as premium shoots up faster than inflation
due to the practice of defensive medicine to avoid litigation. These
factors will make the network of hospitals in India giving reliable
care sooner and cheaper, the ideal partner for overseas health
insurance firms.” According to YP Bhatia, CEO of Delhi based Rajiv
Gandhi Cancer Institute, who heads the CII task force on hospital
accreditation, “The effort is to develop a comprehensive package for
overseas nationals, which will help healthcare do what IT did to the
country. The CII-IHF combine is also drafting a code of ethics on the
relationship among healthcare professionals and institutions.” The
rating agencies CRISIL and ICRA have rated hospitals like the
Escorts Heart Institute and Research Centre and the Apollo group.
The requirement now is for a standard accreditation system. A
quality accreditation institution called The National Accreditation
Board for Hospital and Healthcare Service Providers (NABH) is likely
to be constituted under the aegis of the Quality Council of India. The
NABH will have three committees—Accreditation committee,
Technical committee and the Appeals committee.

The proposed system will assess hospitals based on organisational

and clinical governance, operational management, focus on
patients, clinical services and human resources, while primary
healthcare centres will be assessed on their management and
clinical services by designated agencies under the overall control of
NABH. The challenge lies in getting the consensus and legalisation
of this system done. If it gets delayed in the consensus and
legalisation stages there will be a delay in reaping benefits it can
bring for the medical tourism sector as well. Huge investment is
required to build and maintain this system. There is thus
apprehension about mismanagement of funds and resources as this
task will be carried out on a large scale around the country. There
may be scope for fake accredited hospitals to flourish along with the
well-established ones.

6. Increasing Visibility of India on the World Map

India’s healthcare services cost far less compared to even Thailand,
Singapore and many other healthcare destinations. But it is the poor
visibility on the world healthcare tourism map and poor image of the
country in terms of poverty and basic amenities that deter people
from coming to India. Thailand and Singapore are promoting their
healthcare services aggressively which have turned their countries
into healthcare hubs.

Lately, the government of India, the state governments, the

Confederation of Indian Industry and the Indian Healthcare
Federation have begun promoting India through road shows in some
countries, participating in international trade shows and exhibitions
and placing advertisements in various media abroad. Tour operators
too are taking advantage of this opportunity. Kuoni has tied-up with
the Apollo group, and Cox & Kings with Dr. Batras, Vedic India and
Omkar Trust. More such tie-ups are on the anvil. Tourism packages
specifically designed for the healthcare tourists are being
aggressively promoted by these tour operators. Some hospitals now
have their own Marketing and Public Relations department.
Websites too have been set up for easy availability of information
and for immediate contact.

7. The Impact on Domestic Healthcare Services

India is one of the cheapest healthcare tourism hubs in the world

especially for advanced life-saving surgeries. The inflow of medical
tourists is on the rise in India, and private hospitals are ever ready
to serve this special segment. However, concerns are being raised
about the far-reaching impact of medical tourism on the public
healthcare system that serves a larger section of the Indian society.
Although healthcare services provided by private hospitals in India
to foreign patients are cheap for them, these are still exorbitant for
many Indians. The private hospitals are registered under the Public
Trust Act which makes them liable to provide healthcare services
free up to 20 percent of their resources in return for subsidies
received from the government. But, it is a question that remains
unanswered as to whether they are actually providing free
healthcare services to the public.

Another concern is about increasing concentration of doctors in

urban hospitals. Currently, more than 50 percent of the doctors is
concentrated in the urban hospitals, especially in the metros.
Private hospitals cater to nearly 65% of the healthcare services
market. The number of medical tourists is increasing, which means
demand for private healthcare services will increase. Private
hospitals will need more medical professionals to meet the
increasing demand, and the lucrative offers and the work
environment they offer will attract many. The public healthcare
sector which is disadvantaged vis-à-vis the private hospitals on
these counts will be put under further strain. If more subsidies are
given to private hospitals and changes in regulation made to suit
them, their concentration in the sector will increase. The public
healthcare system will remain neglected. Thus, there is
apprehension about the benefits of medical tourism to the Indian
public.

8. Regulatory system

Medical procedures performed under medical travel carry some risks

that local procedures do not. With surgery conducted as part of
medical travel, a follow-up may be problem and complications, side
effects and post-operative care become the responsibility of the
patient’s home country. Should serious complications arise, patients
might not be covered by insurance due to lack of insurance
portability or might not be able to seek compensation via
malpractice lawsuits. New insurance products that protect the
patient in the event of medical malpractice occurring overseas are
available but with higher cost implications.

Some of the destination countries do not have strong malpractice

laws, so the patient has little recourse to local courts or medical
boards in case surgery or a procedure go wrong. Other medical
travel destinations do provide some form of legal remedies for
medical malpractice. However, this legal avenue is often
unappealing to the medical traveler who plans to spend only a short
time in the country. Advocates of medical travel advise prospective
travelers to evaluate the unlikely legal challenges against the
benefits of such a trip before undergoing any surgery abroad.

Quality issues also continue to be raised in regard to local regulation

covering medical treatment, including facility management and
human resources. While many hospitals indicate that their
specialists have been trained in Western nations, there is less
assurance that training is maintained according to current standards
and that nursing and other staff are equally qualified. The
importance of this issue may lose its significance as more and more
accreditations are given to the medical service providers by
renowned agencies, organisations and institutes.

9. Health equity and ethics

There are increasing ethical issues with greater degrees of medical

travel. The prioritisation of international patients over domestic
patients when public healthcare is often not able to support the
needs of domestic patients has raised serious concerns. Some critics
point to the creation of a two-tier system for health-care delivery
that increases inequalities in health-care access between private
and public systems; sophisticated hospitals with the latest
technology cater to the rich and the foreign tourists, while
underfunded public health systems are left to cater to the poor who
cannot afford access to these new hospitals.

Related to the issue of the stratification of health-care systems,

there exists the fear that subsidies to motivate private sector
hospitals to get involved in medical travel will increase at the cost of
spending on public health. In some countries in the region, the
corporate private sector has already received considerable subsidies
in the form of land purchase and reduced import duties for medical
equipment. Some critics fear that the medical travel boom will only
further legitimise their demands and put pressure on the
Government to subsidise them even more. The already scarce
resources available for health then go into subsidising the corporate
sector. This can have serious consequences for health equity and
the cost of services, and raises a very fundamental question: should
developing countries subsidise the healthcare of developed
countries? For example, in countries where both private and public
hospitals are involved in government-promoted medical travel,
critics fear that in light of expected revenue increases hospitals,
both public and private, are shifting their attention, and most of
their beds, to foreign patients. This highlights the need to consider
implications of medical travel on public health systems and how the
issues facing these entities could be effectively addressed to ensure
comprehensive contributions from health systems to development.
Another example relates to organ transplants. Critics feel that
programmes that encourage foreigners to have transplant
operations may not only mean that local residents who need the
same organs could be pushed down the waiting list; some of them
say it could also lead to an organ-selling spree among the
desperately poor.

On a broader ethical issue, even if the care is excellent, the question

should sometimes be posed whether the procedures are actually
medically necessary or are only undertaken to boost revenue.
Pressure to maximise profits, in a competitive market where it is
necessary to keep costs low, could have a dangerous effect on the
quality of care and the image of the service provider.

10. Dependence on foreign clients

It is important to maintain a balanced portfolio of domestic and

international patients to avoid the excessive reliance on revenue
from international patients. Such revenue is less stable than that
generated from domestic patients. Hospitals with mainly local
patients face a lower business risk since their local clientele needs
their services in uncertain times as well as in good times. While the
income from elective procedures might shrink in a period of
economic hardship, hospital survival is less likely threatened than
that of a hospital, which depends heavily on unpredictable foreign
tourists and conducive environments for travel. However, the
diversification in the composition of the clientele that includes
patients from many different countries could compensate in, to
some degree, minimising the risk associated with dependency.

Domestic political changes and unrest, natural disasters like a

tsunami or an earthquake, possible alterations of economic policies
due to a change in leadership, as well as epidemics, such as SARS
and avian influenza, can potentially affect the number of medical
travelers and investors. Servicing bank loans and other financial
commitments can become very difficult indeed if patients suddenly
do not want to visit a country anymore.

Despite this, many big hospitals and hospital groups aim to grow at
up to 30 per cent per year and this is only possible if they further
increase their share of foreign patients. The local market is just not
growing fast enough to enable such medical institutions to maintain
a balanced portfolio, and the hospitals have little choice but to
increase their intake of international patients. However, as the
dependency grows, so does the risk, especially in the current
competitive market with many suitable alternatives for medical
travelers. Many hospital groups have expanded into other less-
familiar parts of Asia due to intense regional competition for foreign
patients.

11. Techno-centric approach to healthcare

Some researchers fear that medical travel would lead to what is

known as a techno-centric approach to healthcare. This is seen as a
western concept, and something which would increase cost of
healthcare delivery to the general public.

A generic problem with medical travel is that it reinforces the

medicalised view of healthcare. By promoting the notion that
medical services can be bought off the shelf from the lowest priced
provider anywhere in the globe, it is perceived to take away the
pressure from Governments to provide comprehensive healthcare to
all of their citizens. The matter is further complicated by the
competitive pressures brought on by private hospitals on the
resource stricken public health systems. Investments in upgrading
public health systems to keep up with the competitive pressures can
translate into higher costs and thus limited accessibility for the
general public.

The development of traditional medicine systems through the

promotion of holistic health packages to international patients have
the potential to balance out the increasing technocratic approach to
medicine in many developing countries.

12. Portability of health insurance

Medical tourism is resulting in a number of demands and changes in

the areas of financing and regulations. There is a greater push for
encouraging private insurance tied to systems of accreditation of
private hospitals.

There is still a big concern in developed countries about the quality

of care and clinical expertise in developing countries. This concern
will contribute to the push for both insurance and regulatory
regimes.

Portability of health insurance is of vital importance for successful

management of medical tourism. The health insurance systems of a
limited number of countries, such Canada and Japan, have
provisions which allow partial reimbursement of costs incurred on
medical treatment received in other countries, depending on the
type of treatment received and whether the treatment could be
made available within a reasonable time in the home country. In
another example, the European Union allows for coverage of pre-
authorised treatment received in any other Member States.

In many cases, patients travel to Asian countries to receive medical

treatments, because such treatments are not covered by insurance
or because insurance coverage is too expensive. These factors will
continue to make affordable medical care in the region attractive
irrespective of portability.

At the same time, medical tourism is increasingly viewed as a form

of outsourcing; a cost-effective option for providing medical care to
the patients who are covered under health insurance, and benefiting
both the patient and the insurance company. Despite interest that
has been shown by some insurance companies in developed
countries in this regard, issues such as lack of accreditation and
pressure from provider lobbies in developed countries, has hindered
progress in this direction. This issue could be discussed further as
part of negotiations under GATS relating to financial services.

13. Government leadership

There are several ways that governments can support medical

tourism. The Government of India is committed to the goal of
making India a world leader in the industry. Merging medical
expertise and tourism became government policy when the ex-
finance minister Jaswant Singh, in the 2003-2004 budget, called for
India to become a global health destination as one of the three
principal objectives on health. As part of Government commitment
on this, the 2003-2004 budget offered several incentives to promote
the medical tourism industry. For example, in order to encourage
private hospitals to either establish new or to expand existing
medical facilities, it was proposed to make long-term capital more
easily available to private hospitals with 100 beds or more.

To ensure hospitals use the most advanced technology available, it

was further proposed to increase the depreciation rate to allow old
equipment to be replaced sooner. It was also proposed to reduce
the customs duty on specified life-saving equipment from 25 per
cent to 5 per cent, and also exempt such equipment from additional
customs duty.

The Government, in partnership with private hospital groups, is also

taking steps to address medical travel deterrents such as concerns
regarding treatment and care standards, insurance coverage and
general infrastructure. As a result, quality of Indian hospitals has
improved significantly, translating into increased international
accreditation of its hospitals. Insurance coverage for treatment in
Indian hospitals is also increasing. For example, patients treated at
the Wockhardt Hospitals are insured by United States private health
insurers Blue Cross and Blue Shield. The British health insurer BUPA
also insures the costs of treatment at Wockhardt hospitals. In
another example, BUPA also signed a contract with the Ruby
Hospital in Kolkata. At the same time, governments of receiving
countries also have to ensure that medical tourism is not developed
at the cost of the public health system. As medical tourism relates
directly to a core service provided by the government to the public,
it is critical that governments become a stakeholder in the industry.
India is also putting in place policies to support medical
tourism. India’s National Health policy 2002, for example,
says:

“To capitalise on the comparative cost advantage enjoyed by

domestic health facilities in the secondary and tertiary sector, the
policy will encourage the supply of services to patients of foreign
origin on payment. The rendering of such services on payment in
foreign exchange will be treated as ‘deemed exports’ and will be
made eligible for all fiscal incentives extended to export earnings”.

The formulation draws from recommendations that the corporate

sector has been making in India and specifically from the “Policy
Framework for Reforms in Healthcare”, drafted by the prime
minister’s Advisory Council on Trade and Industry. This indicates a
mature multi-ministerial collaboration.

14. International Cooperation

As healthcare companies integrate across national borders, they

create an international market for healthcare services. Even if
medical tourism used to be a lifeline for these healthcare
corporations, such as the case during the Asian financial crisis, the
synergy created by corporations expanding and integrating across
national borders, in turn, encourages the further expansion of the
medical tourism market.

Pro-active negotiations and agreements among receiving and

sending countries may result in lower costs. The potential for
cooperation is also strong in areas such as information collection
and exchange in a set format; portability of health insurance;
accreditation; liability and patient confidentiality issues; and patient
facilitation measures through inter-country agreements.

15. Availability of reliable and complete information

There is a lack of reliable information sources on the extent of

medical tourism in the region, especially relating to the number of
foreign patients treated, revenue earned and choices of treatment.
Most of the available information is anecdotal and drawn from
newspaper and magazine articles; often sufficing only to indicate
trends. Destination facilities publicise how many international
patients they treat, but because these figures are often used as
marketing devices they must be treated with caution. Beyond
popular news media coverage, information available on the websites
of medical tourism companies and a small body of scholarly
literature, little information is available. Countries, such as Thailand
and Malaysia, have made some attempts to collect information in a
structured manner. However, there is a clear need for increased
effort to collect and exchange reliable information on medical
tourism. This would help in clearly quantifying the benefits and
identifying potential negative impacts, allowing timely policy
interventions.
Patient mobility should be managed. The scope for market failure in
healthcare is well recognised, in particular, because of the extent of
information asymmetry. Except in the most straightforward of
circumstances, there will be dangers in relying simply on market
forces.

Opportunities For Health Systems In Medical Tourism

Economic gain

Medical tourism contributes to the growth of health economies. It is

a major source of foreign exchange and stimulates economic growth
in other sectors as well, including tourism, transport,
pharmaceuticals, hotels, food suppliers to hospitals and restaurants.
The tourism market is particularly lucrative, as tourism is an integral
part of many economies’ services industry and an important source
of foreign exchange. The labor-intensive nature of the tourism
industry makes it an excellent generator of employment.

Reducing external brain drain

The international service trade has greatly affected the health-care

systems in developing countries. The last four decades were
characterised by massive emigration of physicians from developing
countries, such as Thailand and India, to developed countries, such
as the United States of America, in response to increasing demand
and higher wages. In this way, Thailand lost about 1,500 physicians,
20 per cent of its total number, in the period 1965-1975.

Anecdotal evidence from countries, such as India and Thailand, now

indicates that large numbers of medical graduates, who acquired
specialised medical degrees in developed countries, are finding it
lucrative and more satisfying to return to their own countries.

Modern hospitals that make a significant investment in facilities and

staff, in part to compete for international patients, now also provide
the benefits and working conditions to satisfy the aspirations of
medical professionals who would otherwise move outside the
country.
A good example is Bumrumgrad Hospital in Thailand; the majority of
its 600 Thai health professionals has overseas training and
certification, mainly in the United States of America, but preferred to
return to work in Thailand. In India, increasing numbers of medical
graduates are also returning to serve in modern hospitals serving as
medical tourism centres.

It should be noted that Thai medical professionals are still traveling

abroad for work. Except this time they are traveling on behalf of
their Thai employer to take up residency at the joint ventures
medical centers that Thai private hospitals are increasingly investing
in.

Improved medical infrastructure

Medical tourism and the competition on the global health market

promote technological advances and improved medical
infrastructure. To attract international patients, hospitals must
invest in high-quality facilities, cutting-edge technology and human
resources. This necessity sets a higher standard for healthcare than
many public hospitals are now measured against, and could drive
public hospitals to invest in their own medical infrastructure and
possibly revitalizing weak health-care systems.

International accreditation is sought by healthcare providers

involved in medical tourism, as well as demanded by patients and
medical tourism facilitators. In a number of countries, this has lead
to increased emphasis on consistent good quality that may create
pressure on other private healthcare providers and public facilities
to emulate them, at least in part.

The medical tourism centers in developing countries not only

provide options for patients from developed countries, but also for
medical professionals and patients from within the country and from
neighboring countries. Such centers provide stimulus for
professional development, training and professional tenure within
reach of the domestic population in terms of physical accessibility,
and lesser costs compared to similar treatment in developed
countries.

Summary
 India has a wide network of public and private hospitals; most of the healthcare
services are provided by the private sector. Public sector institutions are run by
the Central or State government bodies, whereas private hospitals are managed
by trusts as a profit or not-for-profit organisation.
 The issues that need attention in the Indian medical industry are:

o Upgradation of basic amenities and hospital infrastructure

o Co-ordination between the healthcare and tourism sectors

o Creating a resource pool of highly skilled and cordial manpower

o Internal Brain Drain

o Standardization of services and accreditation of hospitals

o Increasing visibility of India on the world map

o The impact on domestic healthcare services

o Regulatory System

o Health Equity and Ethics

o Dependence on foreign clients

o Technocentric approach to healthcare

o Portability of Health Insurance

 Government Leadership

Topic 14: MT-The Future of Health Services

1. Objective
At the end of this chapter the student will be able to:

 Understand the emerging concepts in medical tourism.

 Discuss the Porter’s diamond international trade theory in context with medical
tourism.

Introduction
Travel itself exposes travelers to various mental and physical
challenges in their new environment as part of their experience
(Freedman and Woodhall 1999; Cetron, et al. 1998; Isaacson and
Frean 1997; Lederberg 1997; Morse 1995; Wilson 1995). This is
especially so when the medical tourist is ill and debilitated and,
therefore, more susceptible to contracting illnesses from the
destinations. However, the cost benefit for the traveling medical
tourist to receive medical treatment often compensates for this
travel risk at the destination.

There are numerous definitions of tourists (Theobald, 1998).

However, it is accepted that tourists are travelers who have traveled
and stayed away from their home environment for 24-hours or
more, and hence, have often utilised some form of accommodation
facility. Those travelers who do not meet this 24 hour criterion are
generally referred to as ‘visitors’. For travelers that travel overseas
for medical purposes, conceptually, they would meet the definition
of a tourist. Since medical tourists are travelers whose main
motivation for travel is for a specific purpose, medical tourists can
be categorised as a group of special interest tourists, hence
participating in a form of special interest tourism (Douglas, Douglas,
and Derrett, 2001).
Figure 1: Medical and healthcare tourism and components

There is no one definition for medical tourism but it is generally

accepted that this term is used to refer to travel activity that
involves a medical procedure or activities that promote the
wellbeing of the tourist. Figure 1 illustrates the components of
medical and healthcare tourism (TRAM, 2006).

The term ‘treatment of illnesses’ generally includes medical check-

ups, health screening, dental treatment, joint replacements, heart
surgery, cancer treatment, neurosurgery, transplants and other
procedures that require qualified medical intervention. These can
range from healthcare services that can be provided by a local
general practitioner to complex surgical procedures such as
transplants. ‘Enhancement’ procedures are carried out mainly for
aesthetic purposes. Some of these procedures require qualified
medical personnel but much of this work is non-disease related
(unless disfigurement is caused by disease). Examples of such
procedures include all cosmetic surgery, breast surgery, facelifts,
liposuction and cosmetic dental work.

This component of the tourism and healthcare tourism is traditionally

most associated with the tourism and leisure industry. The ‘wellness’
segment of medical and healthcare tourism promotes healthier
lifestyles (Bennett, King and Milner, 2004). Therefore, these products
can include treatment in spas, thermal and water treatments,
acupuncture, aromatherapy, beauty care, facials, exercise and diet,
herbal healing, homeopathy, massage, spa treatment, yoga and other
similar products. There is normally no need for a qualified doctor to
provide these services, although many professionals providing these
services, are often accredited members of the various associations.
‘Reproduction’ tourism is an increasing and growing area of medical
tourism travel. Under this component, there are patients who seek
fertility-related treatments such as in vitro and in vivo fertilisation and
other similar procedures. In some situations, the travel is motivated
and influenced by the legislation in the country of origin and host
country. Some fertility procedures are illegal in some countries.
Furthermore, ‘birth tourism’ is also included in this category (TRAM
2006). This category involves a pregnant mother who travels to
another country to give birth to her baby in order to utilise the
services, which are often free. In addition, a further advantage for her
is to have her child gain citizenship of the new country and thus be
able to reside permanently in the new location. At times, potential
parents travel for the purposes of adopting children because the
legislation and supply of babies for adoption is easier in host countries.

Porter’s Diamond
Porter’s diamond of national competitive advantage is a modern
international trade theory (Porter, 1990). It was derived and used to
conceptualise the four conditions that are important when
conducting international business. These four factors originate from
earlier country and firm-based theories. In simple terms, the country
based theories relate to the international trade theories of nations
as a unit of business and the firm-based theories are those which
relate to the firm as a unit of business. International business can be
defined as commerce or business involving one or more countries
and/ or businesses located in a different country (Fisher, Hughes,
Griffin and Pustay, 2006). In either situation, it involves cross-border
or trans-border commercial activities, hence including the
complexities arising in different legislation, political environments,
cultures, societies and other factors. As medical tourism generally
involves the participation and activities of people and transactions in
more than one country, this is appropriately relevant to international
business. Originally, Porter’s diamond of national competitive
advantage was developed from the observations of the practices of
about one hundred international businesses across ten different
countries. Therefore, many of the components would encompass
and consider most of the elements that are essential for the
strategic decision-making of a firm intending to conduct
international business. In the shape of a two-dimensional diamond,
four main components are included in this model (see Figure 2).
These include factor conditions, demand conditions, related and
supporting industries, and firm strategy, structure and rivalry. Two
additional, elements, which refer to chance and government, were
later included in the conceptualisation to recognise the importance
of these two additional components in the influence of international
business.

Figure 2: Porter’s diamond of national competitive advantage

Source: Porter (1990)

Factor conditions

With factor conditions, many medical tourism products are located

in warm, pleasant environments. Therefore, the basic factors, which
include ideal climatic conditions, natural resources and geographic
location, are an advantage for medical tourism especially for those
visitors from colder climates. In addition to these basic factors, there
are advanced factors that have assisted in the development of
medical tourism. These include investments made by people, who
usually offer medical tourism services, predominantly in private
hospitals (companies) and governments. Other advanced factors
include the utilisation of the world-wide web resources for the
communication and marketing of the medical tourism product
internationally. In terms of quality, it is said that there is little
difference in the medical tourism services offered in the advanced
western countries and those in the eastern or developing countries.
Quite often, medical doctors and their staff are trained in western
countries, have worked in western hospitals and then returned to
their country of origin (eastern or developing countries) for various
personal reasons (CBS, 2004; 2005). Furthermore, the recruitment
of foreign-trained doctors by these private hospitals, plus attractive
work conditions have helped to staff these hospitals with well-
qualified people. Therefore, the quality of such healthcare services
are equivalent and the services far better than that found in the
hospitals in developed countries.

Labour, in a large population, is relatively cheap in developing

industries. Therefore, many of the activities involved in financing a
hospital can be managed at a cheaper cost because salaries are
generally lower and, in turn, the savings are passed along to the
patient who pays much less for the same healthcare service than
that found in their home country.

Demand conditions

As the aging population increases, there is increasing demand for

medical services, and, quite often, this demand cannot be met in
many western countries under the public healthcare service. For
much of the population, private healthcare is too expensive and so
patients are placed onto public waiting lists for medical treatment.
As these lists get longer and the price of healthcare increases, it is
logical that alternative measures, which can serve this necessary
demand, will be supported to improve the quality of life of these
patients. Quite often, simply the cost of an expensive holiday could
finance medical treatment and a recuperative break away in the
destination country. This is very attractive for many people. Both
physical and mental well-being are addressed (Garcia-Altes, 2005;
Henderson, 2004). The former is taken care of by surgical
procedures, the latter involves recuperation and pampering in an
exotic location that can promote mental health and wellbeing during
this process. Hence, such a medical tourism experience is very
attractive. A further demand for medical tourism is created by the
increasing population that does not subscribe to private healthcare
insurance. There are various reasons why some people do not have
medical insurance - these are usually cost-related. Consequently,
this would be a group of patients who would either benefit from
medical tourism, or, not be able to afford any treatment at all.
Insurance companies that have to pay for the cost of medical
treatment of their insured clients are continuously seeking ways of
reducing their expenses and improving their services. These
companies are gradually creating a demand for medical tourism as
well. Where companies allow flexible claims for healthcare services,
these companies may pay a smaller amount of compensation to
their clients who have paid less for their medical treatment received
overseas. For example, India has targeted the National Health
Service to explore the use of medical services overseas. Such
international business arrangements are somewhat like a
sophisticated form of subcontracting or off-shoring of services,
which is a commonly utilised business strategy to reduce costs.

Related and supporting industries

Since medical tourism involves a form of travel to a foreign location,

there is demand for some form of accommodation in the hospital or
in a hotel and also for local travel at the destination. Therefore,
medical tourism relies upon a developed infrastructure. The tourism
industry includes the provision of travel by the airlines and
accommodation in hotels and motels and also taxis for local travel.
Furthermore, there are activities that cater for the leisure and
recreation of tourists, which can provide ideal facilities for a relaxing
and pampered recovery from any medical procedures. With such
sound infrastructures in place in most developing countries, not
much further infrastructure investment is required by local
businesses and host governments. In addition, foreign governments
are aware that the value of the tourism dollar can be increased by
the introduction and support of medical tourism and so have
supported businesses investing in this new industry. Furthermore, it
is recognised that a medical tourist rarely travels alone. It is
common for another relative to accompany the patient and,
therefore, the accompanying person or entire family may travel to
the selected destination and stay for the necessary duration of the
medical treatment. Governments further encourage medical tourism
by allowing visas to be easily obtained and so do not hinder the
process.

Company strategy, structure, and rivalry

This factor shifts from the macro-related (at country level) toward
those at a micro level (at level of the firm) in the Porter’s diamond.
At a micro level, the future of individual enterprises (including
hospitals) participating in medical tourism will be dependent on their
strategy, structure and rivalry. Although medical tourism is
supported by governments, as with other tourism businesses, those
companies, which do not provide a quality service and maintain a
good customer satisfaction rating, cannot remain sustainable in the
market environment. As medical tourism becomes more attractive
to many countries, there will be much more international
competition and rivalry. Therefore, with medical treatment being
equal across many countries, the tourist would begin to select their
target destination based on other reasons. Some medical
enterprises have compiled packages to make it easier for tourists
who then do not need to spend so much time in researching their
travel and accommodation requirements (Medical tourism, 2005a;
2005b). With the medical tourism facilities increasing in demand
over time, as with other international business operations, there is
room for multinational enterprises that can offer such healthcare
services internationally. With a multinational enterprise comprising
staff that is recruited internationally, there are facilities within the
structure of the firm to enable these enterprises to expatriate
medical staff to manage future subsidiaries around the world.
Although doctors are required by law to register with the local
medical associations before they can practice in the local
environment, there is no such requirement for the CEO to manage
and start such operations in any country. Thus, it will not be unusual
in the near future to have different forms of entry modes in medical
tourism, such as with franchising agreements or joint ventures.
 Table 1 lists a range of countries that are currently offering
international medical tourism healthcare services. This table shows
that almost all the countries in the world offer some form of medical
tourism services. As the benefits of medical tourism is realised in
financial terms and for the wellbeing of the patients, more resources
from governments and private investors in this industry will be
provided.

Table 1: International medical tourism provision of service

Czech
Argentina Bulgaria Republic Iran Mexico Saudi Arabia

Australia Canada Dubai Israel Netherlands South Africa

Cayman
Bahrain Islands France Japan Oman Switzerland

Bangladesh Chile Germany Jordan Peru Taiwan

Barbados Costa Rica Greece Korea Philippines Thailand

Belgium Cuba Hungary Lebanon Poland Turkey

Brazil Cyprus India Lithuania Romania

Malaysia Russia

Source: TRAM (2006)

Keeping Up With Developments

As with all rapid developments, there will be some need to regulate
and monitor institutions in order to ensure and maintain the health
and safety of medical tourists. It is more likely that this process will
be reactive to issues and problems rather than proactive in
preventing problems from emerging. With some medical tourism
procedures, such as heart surgery, hip replacements, cochlear
implants and dental surgery, it is necessary to be aware of the
qualifications and training of surgeons, operating teams and the
reputation of the medical facilities offering the treatments. It cannot
be taken for granted that the same level of health standards apply
in the domestic and international environment. Nevertheless, the
utilisation of overseas health services is not too different from the
better known subcontracting or the off-shoring of services, such as
those used in call centers and other business services. Since
medical tourism decisions are sometimes based on higher costs and
average expertise in the domestic situation (in comparison with the
cost of medical services abroad at lower prices and sometimes of
better quality), medical tourism is likely to be the new global trend
for providing medical services through necessity rather than a
choice for many future medical tourists.

With the range and scope of medical procedures offered in the

international marketplace, different countries offer different levels of
control over their domestic medical tourism services. This can be
risky and dangerous (Menck, 2004). In the worst case scenario,
either post-operative recovery does not go well and patients need to
prolong their stay at the destination and therefore incur additional
costs, or, if patients have returned home, they would have to seek
further medical care and treatment in their home country. This
would increase the cost of the overall treatment for their condition
especially for cosmetic procedures, which are monitored less
(Connell, 2006). Hence, ‘buyers beware’ is currently the norm than
the exception. Therefore, in the early days of global investment in
this new product, the monitoring or accreditation of these products
can significantly increase their international demand. The way
forward is towards some form of international monitoring of the
global medical tourism product and services at governmental and
global levels. This would require a large degree of international
coordination and cooperation between the nations beyond that
exhibited by the current day situation.
Conclusion

Medical tourism is becoming a new and emerging international

business that is gradually increasing in importance. In capitalizing
on the tourism infrastructure that supports this industry, nations do
not need to invest much more in supporting medical tourism. As an
international business, this is not too different from the
subcontracting or the off-shoring of services. With higher costs and
expertise, in the future, medical tourism is likely to be the new
global trend for providing medical services. The rapid developments
in medical tourism demands have left the policing and legislation
behind. It would be imperative for this legislation to catch up in
order to protect the vulnerable that are unable to make well-
informed research-based decisions. It remains to be seen in the
future which countries will adopt the proactive stance to
strategically avoid future problems to maintain and protect their
country’s reputation in this important and growing area
of healthcare.

Summary
 Porter’s diamond of national competitive advantage is a modern
international trade theory (Porter, 1990). It was derived and
used to conceptualise the four conditions that are important
when conducting international business.
 Medical tourism is becoming a new and emerging international
business that is gradually increasing in importance. In
capitalising on the tourism infrastructure that supports this
industry, nations do not need to invest much more in supporting
medical tourism.