Medical visas mark growth of Indian medical tourism

164 Bulletin of the World Health Organization | March 2007, 85 (3) News Medical visas mark growth of Indian medical tourism India’s medical tourism sector is a growing source of foreign exchange as well as prestige and goodwill outside the country. Having supported medical tourism’s rapid growth, the government is under pressure to find ways to make the sector of benefit to public health services that are used by most of India’s 1.1 billion population. Woman being treated for cholera in poor-resourced Indian hospital. The contrast between some public hospitals and the new centres of medical excellence in India is stark. SE AR O /W HO Indian consulates and missions abroad face a growing number of inquiries about “M” or medical visas. The Indian Ministry of Tourism’s 13 overseas offices are stocked with in- formation for those intending to travel to India for medical treatment. The new M-visas are valid for a year and are issued for companions too. Howard Staab, a 53-year-old from the United States, is one such tourist. His smiling face figures in the glossy brochure on medical tourism produced as part of Incredible India, the govern- ment’s big-budget marketing campaign to attract tourists. India’s efforts to promote medical tourism took off in late 2002, when the Confederation of Indian Industry (CII) produced a study on the country’s medical tourism sector, in collabora- tion with international management consultants, McKinsey & Company, which outlined immense potential for the sector. The following year, then finance minister Jaswant Singh called for the country to become a “global health des- tination” and urged measures, such as improvements in airport infrastructure, to smooth the arrival and departure of medical tourists. Medical tourism is an example of how India is profiting from globalization and outsourcing. It is also a new form of consumer diplomacy, whereby for- eigners who receive medical services in India help the country to promote itself as a business and tourism destination. India hosts medical tourists from industrialized countries, such as the United Kingdom and the United States, but also from its neighbours Bangla- desh, China and Pakistan. It faces in- tense regional competition in this sector, particularly from Malaysia, Singapore and Thailand. A wide-range of services are on offer. Ministry of tourism brochures advertise cardiac surgery, minimally invasive surgery, oncology services, or- thopaedics and joint replacement, and holistic health care, provided by about 45 hospitals promoted as “centres of excellence”. Health tourism is often hailed as a sector where developing countries, such as India, have huge potential due to their comparative advantage based on providing world-class treatment at low prices combined with attractive resorts for convalescence. The CII estimates that 150 000 medical tourists came to India in 2005, based on feedback from the organiza- tion’s member hospitals. Figures for M-visa entrants are not readily available. CII spokesperson Aditya Bahadur told the Bulletin that patients prefer to come on ordinary tourist visas to avoid the M-visa’s requirement that they register with the regional authorities within two weeks of arrival. A ministry of tourism brochure predicts a “phenomenal expansion” of the Indian health-care industry. According to the Federation of Indian Chambers of Commerce and Industry, the health-care market, which includes health insurance, is expected to expand by 2012 from US$ 22.2 billion, or 5.2% of gross domestic product (GDP), to between US$ 50 billion and US$ 69 billion, or 6.2% and 8.5% of GDP. While impressive, these figures do not address the divide between facili- ties oriented towards medical tourism and those that cater to the health needs of the average, usually rural, Indian. According the World Health Orga- nization (WHO), private expenditure on health as a percentage of total expen- diture on health in 2003 was 75%. That contrasted starkly with government expenditure of 25% in the same year, a portion which finances public health facilities that cater to most of India’s population. Fewer than 50% of India’s primary health centres have a labour room or a laboratory, while fewer than one in five have a telephone connection, according to the 2005 Reproductive and Child Health Facility Survey. Moreover, fewer than one in three primary health-care centres stocked essential drugs, in contrast to the situation in many new urban medical centres. Health care in India’s rural districts is poor, dogged by shortages of trained health workers, a lack of funds and cor- ruption. Many patients resort to quacks or seek no medical care at all, since private practitioners are beyond the means of most. In contrast, to provide a guarantee of service quality for medical tour- ists, the Indian Ministry of Health has begun accrediting hospitals and recom- mending prices for services. So far 35 hospitals have applied for accreditation. CII has a certification system and has already approved 30 of its 120 hos- pital members. Under the CII system, certified hospitals must agree to limit charges to foreigners as part of a dual 165Bulletin of the World Health Organization | March 2007, 85 (3) News Navy labs play public health role A United States network of laboratories, initially created to protect the health of US service personnel by doing local research and disease surveillance, has become a major public health presence in the developing countries where it operates. pricing-system that offers domestic pa- tients lower prices. Non-resident Indian medical tourists are charged the same as any others from abroad. Still, even these lower prices are too high for the vast majority of India’s 1.1 billion population. The CII group, which also has an ethical code for mem- ber hospitals, is establishing a regulatory framework for its own members, raising questions about how effective such self- imposed rules can be. CII lawyers are also drawing up a standard contract to ensure that any litigation, arising from treatment, is dealt with in Indian courts. Currently, neither medical tourists nor Indian patients can take their cases to Indian courts. Their only recourse is India’s State and National Consumer Disputes Redressal Commissions, which have a huge backlog. “Any litigation launched against an Indian hospital will expose the poor system of justice that exists here,” said Dr Mohan Thomas, medical direc- tor of the Cosmetic Surgery Institute in Mumbai and Chairman of CII’s Healthcare Committee. But while helping to strengthen medical tourism, the Indian government is coming under increasing pressure to use these foreign exchange revenues to benefit the ailing and under-resourced public health system. The private sector hospitals argue that trickle-down payments for hotels and other services will improve the economy as a whole. But public health advocates say that, unless the Indian government actually allocates more of its revenues to public health systems, the impact will be negligible. “The government has not examined how our patients will benefit [from medical tourism] or whether they will lose out,” Dr Nilima Kshirsagar, dean of one of Mumbai’s largest public hospi- tals, the King Edward Memorial, told the Bulletin. “The need to benefit Indian patients is the main goal, and medical tourism cannot be at their cost.” Prime Minister Manmohan Singh recently acknowledged the need improve public health care: “There are many parts of our country where public-sector intervention in health is absolutely essential to carry conviction with our people and to improve the quality of delivery of services.” As the medical tourism sector grows, however, little is known about the impact this is having on its health workforce. Private hospitals argue that medical tourism reverses the brain drain and that health workers, who are mi- grating to economies where salaries are higher and career opportunities more attractive, will stay in India if they can work in the medical tourism sector. There are fears, however, that medi- cal tourism could worsen the internal brain drain and lure professionals from the public sector and rural areas to take jobs in urban centres. “Although there are no ready figures that can be cited from studies, initial observations suggest that medical tourism dampens external migration but worsens internal migration,” said Dr Manuel Dayrit, director of WHO’s Human Resources for Health depart- ment. “It remains to be seen how sig- nificant these effects are going to be. But in either case, it does not augur well for the health care of patients who depend largely on the public sector for their services as the end result does not contribute to the retention of well- qualified professionals in the public sector services,” Dayrit said. Dayrit disagreed with medical tour- ism proponents, who argue that some revenues from medical tourism will find their way into public coffers to help retain staff in the public sector. “Unless national laws or regulations are set up so that these revenues are taxed explicitly and channelled to the public sector to augment salaries, the likelihood of this happening is very slim,” he said. O Rupa Chinai and Rahul Goswami, Mumbai When bird flu was first detected in Egypt in February 2006, it was a US naval laboratory that confirmed the samples received from Egypt’s govern- ment laboratory were of the H5N1 sub-type, before forwarding them to the US Centers for Disease Control and Prevention (CDC) for further confirmation. “Keeping sailors, soldiers, airmen and marines healthy and out of hos- pital” is still the United States’ Naval Medical Research Units’ (NAMRU) primary and original mission, accord- ing to Andrew Stegall, public relations officer at NAMRU-3 in Egypt. But, over the years, NAMRU’s work has be- come part of the public health systems of the developing countries where it is based. Since NAMRU was founded in the 1940s, it has become the largest overseas military medical research facility in the world and emerged as an important for- eign policy vehicle of the United States. US naval personnel and scientists at these centres in Egypt, Ghana, Indonesia and Peru collaborate with lo- cal research groups, particularly in the areas of vaccine development, disease surveillance and vector control for tropical diseases. They also train local scientists to do more research relating to public health problems. NAMRU’s research often involves local children because their immune systems are the best approximate to those of US military personnel and any- one who has not developed immunity to local diseases. “We are most interested in how Egyptian children react to diseases because they are seeing the region’s diseases for the first time. Human body immune systems have memories, and children’s systems aren’t fully devel- oped to their habitat,” Captain Robert Frenck, Jr was quoted as saying in All Hands, the US navy magazine in February 2004. Andrew Stegall, public relations officer at NAMRU-3 in Egypt, said it was mutually beneficial because they share their findings with the local au- thorities: “This gives the country a start process of developing their own capabil- ity of surveillance and treatment”.