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DISSERTION ON MEDICAL TOURISM IN INDIA UNDER THE GUIDANCE OF Mrs. Radhika Meenakshi SUBMITTED IN PARTIAL FULFILLMENT OF THE 3 YEAR COURSE OF BACHELOR OF BUSINESS ADMINISTRATION (2005-2008)
Sharanjeet Singh Baath A111OIO8C52
My gratitude goes to my mentor Ms. Radhika Menakshi, who has guided me through out this project and also my respected teachers Professor Alka Munjal, Ms. Ekta Kapoor and Ms.Supriya Bhasin at the Amity University for giving me the substantial knowledge and inspiration. I would also like to thank Marketing Executives of indraprastha Apollo , Max Hospital, Fortis and Escorts for constant guidance to conduct the present arduous project and untiring cooperation which they extended to me throughout the duration of my dissertation. I am thankful to the Amity Business School Library for allowing me access to information and knowledge My special thanks are for those who spared time for providing information and responding to the questionnaire.
Sharanjeet singh Baath A1110108C-63
Amity School of Business CERTIFICATE
This Dissertation report on _______________________________ is submitted in partial fulfillment of the requirement of Bachelor of Business Administration (BBA), Of Amity School of Business, Amity University Uttar Pradesh.
work class of
conducted 2008; under
guidance of ______________________ (industry guide) and _____________________(faculty guide).
TABLE OF CONTENTS
• INTRODUCTION 6- 9
a) Brief description of Healthcare industry. b) Healthcare in India c) Tourism in India d) Medical tourism e) Review of literature
• MEDICAL TOURISM 10-39
• • • • • • • • • Objective and sub objectives Research methodology Research design Data collection sources Primary data Secondary data Sample size Limitations of the study Parameters and criteria for the viability of the project 40 41
CHAPTER 4 MARKET VIABILITY OF INDIAN HEALTHCARE INDUSTRY 43-55
• Segmentation • Marketing mix • Demand forecast CHAPTER 5
SAMPLE BACKGROUND a) b) c) d) Apollo FORTIS Max Hospital Escorts 55-58 58-60 60-61 61-64
Analysis and interpretation 65-71
Findings Conclusion Recommendation CHAPTER 8 APPENDIX Bibliography Questionnaire 77-78 79-80 72-73 74-75 76
The health care industry is considered an industry or profession which includes peoples exercise of skill or judgment or the providing of a service related to the preservation or improvement of the health of individuals or the treatment or care of individuals who are injured, sick, disabled, or infirm. The delivery of modern health care depends on an expanding group of trained professionals coming together as an interdisciplinary team.
HEALTHCARE IN INDIA
Healthcare in India is the responsibility of the individual Indian states. The Indian constitution charges those states with "the raising of the level of nutrition and the standard of living of its people and the improvement of public health". There is also a National Health Policy, endorsed by Parliament in 1983.
TOURISM IN INDIA
Welcome to Incredible India, where culture echoes, tradition speaks, beauty enthrall and diversity delights.
Indian tourism is one of the most diverse products on the global scene. India has 26 world heritage sites. It is divided into 25 bio-geographic zones and has wide ranging eco tourism products. Apart from this, India has a 6,000 km coastline and dozens of beaches. . It also has one of the world's biggest railway systems opening possibilities for those interested in rail tourism. India also has excellent hospitals offering affordable Medicare and traditional healthcare systems like Ayurveda.
Medical Tourism refers to movement of consumers to the country providing the service for diagnosis and treatment. During the past few years, the number of people going out of their home country to consume health services has significantly increased. The size of this market is estimated to be $40 billion based on a Saudi Report in 2000. During the past four years, the market grew at a whopping rate of 20-30% and is expected to grow further. Considering this growth the current market size is estimated to be $100 billion. Medical Tourism industry offers tremendous potential for the developing countries because of their low-cost advantage. The advantages of medical tourism include improvement in export earnings and healthcare infrastructure.
Medical tourism can be broadly defined as provision of ‘cost effective’ private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public.
REVIEW OF LITERATURE
• An estimated 150,000 "medical tourists" visited India last year, representing a 20 per cent jump over the previous year. • The CII-McKinsey report suggests that medical tourism could fetch as much as $2 billion by 2012, compared to an estimated $333 million currently. • Ayurveda tourism earned RS.6000 crore last year • A Famous Mumbai and Goa based cosmetic surgeon says his practice goes 1200 international patient last year, double the number from previous year Source- http://en.wikipedia.org/wiki/Healthcare_in_India
Medical Treatment in USA Equals to A tour to India + Medical Treatment + Savings
(SOURCE CII-MCKINSEY REPORT)
• "First World treatment' at Third World prices".
Patients from the UK and North America make up a little more than a trickle right now, but there is big potential for growth," said Mr Anil Maini, head of healthcare business marketing at the Escorts Heart Institute and Research Centre, New Delhi Source -The Washington.Thursday October 21st 2004.
• 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. Source- www.indiamedicaltourism.com
The purpose here is to provide you with up to date information and resources about the rapidly growing industry known as "medical tourism" so that you may make educated and well informed decisions regarding your travel, accommodations, and medical, dental, and surgical care. It is my sincere hope that the information provided here will assist and empower you to make confident decisions regarding your health and well being.
The countries where medical tourism is being actively promoted include Greece, South Africa, Jordan, India, Malaysia, Philippines and Singapore. India is a recent entrant into medical tourism. According to a study by McKinsey and the Confederation of Indian Industry, medical tourism in India could become a $1 billion business by 2012. The report predicts that: "By 2012, if medical tourism were to reach 25 per cent of revenues of private up-market players, up to 2,297,794,117 USD will be added to the revenues of these players". The Indian government predicts that India's $17-billion-a-year health-care industry could grow 13 per cent in each of the next six years, boosted by medical tourism, which industry watchers say is growing at 30 per cent annually. Price advantage is a major selling point. The slogan, thus is, "First World treatment' at Third World prices". The cost differential across the board is huge: only a tenth and sometimes even a sixteenth of the cost in the West. Open-heart surgery could cost up to $70,000 in Britain and up to $150,000 in the US; in India's best hospitals it could cost between $3,000 and $10,000. Knee surgery (on both knees) costs 350,000 rupees ($7,700) in India; in Britain this costs £10,000 ($16,950), more than twice as much. Dental, eye and cosmetic surgeries in Western countries cost three to four times as much as in India.
India have a lot of hospitals offering world class treatments in nearly every medical sector such as cardiology and cardiothoracic surgery, joint replacement, orthopaedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. The various specialties covered are
Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Paediatrics, Paediatric Surgery, Paediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Medicine. Gynaecology, Pulmonology, Psychiatry, General
For long promoted for its cultural and scenic beauty, India is now being put up on international map as a heaven for those seeking quality and affordable healthcare. Analysts say that as many as 150,000 medical tourists came to India in 2004. As Indian corporate hospitals are on par, if not better than the best hospitals in Thailand, Singapore, etc there is scope for improvement, and the country is becoming a preferred medical destination. In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals.
Leisure Tourism is already very much in demand in India as the country offers diverse cultural and scenic beauty. India has almost all sort of destinations like high mountains, vast deserts, scenic beaches, historical monuments, religious temples etc. Known for its hospitality for tourists, the county has opened doors to welcome with the same hospitality f medical patients/ service seekers.
MEDICAL TOURISM AS AN INDUSTRY
Medical tourism can be broadly defined as provision of ‘cost effective’ private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public.
In many developing countries it is being actively promoted by the government’s official policy. 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 Health Care”, drafted by the prime
minister’s Advisory Council on Trade and Industry, headed by Mukesh Ambani and Kumaramangalam Birla.
2.Overview Of Medical Tourism In Global Scenario
Countries from where people head for India are UK, Bangaladesh, Oman, SriLanka, Indonesia, Mauritius, Nigeria, Kenya, and Pakistan etc. The international patients can make decision by looking at the following table, which shows charges against the type of surgery.
Procedure Charges (US $) Category US Heart Surgery 30,000 Bone marrow transplant 250,000 Liver transplant Orthopaedic Surgery 300,000 20,000
INDIA 8000 69,000 69,000 6,000
India offers a real good cost advantage over the western countries. This cost factor becomes very important while formulating schemes to attract the Indian diaspora as they generally compare the relative costs before going for treatment.
Healthy Budget table
Heart Surgery Costs $ 30,000 ( Rs 14.4 lakhs) in the US, But Indian Hospitals charge Rs 4 Orthopedic Surgery Lakh. In the west, the expense comes to $20,000(Rs 9.6 lakh). The package in Cataract Surgery Liver Transplant India costs one third of that amount. $20,000 is the price for surgery in the US. In India, it comes to just $500 The cost comes to a whopping
$300,000 abroad while Indian super specialty hospitals perform the
Global Medical Tourism
No Country Foreigners treated year last of From Money Earned Strengths
Cosmetic surgery, Organ transplants, Dental treatment, Joint replacements
Organ transplants, Fertility treatment, Cardiac care
Bangaladesh, UK, Developing 85,000 countries US, Japan,$40 m Developing countries 50,000 US, UK N.A
Replacements, Lasik Cosmetic surgery
Cosmetic surgery, Lasik. Dental treatment
Treatment Costs ($)*
10,000- 20,000 1,252
5,000- 10,000 13,333
Medical Travelers Clusters
The first is made up of the SAARC countries.
The second major group- the African (Nigeria ,Nambia etc) The third big group of medical travelers comes from the Middle East .
The last group of medical travelers from a motley lot
Outsourcing of logistics has changed over the years we have seen business models adapted to meet the needs of the buyer. Hospital major areas like house keeping, Food and Beverage, Lenin, diagnostics labs, medical
equipment, ambulatory services etc are outsourced. Hospital focuses on core activity of patient care. Medical Business Process Outsourcing includes Medical coding, Billing, Claims Processing, Transcription etc.
6.1 GROWTH OF THE MEDICAL TOURISM INDUSTRY
The countries where medical tourism is being actively promoted include Greece, South Africa, Jordan, India, Malaysia, Philippines and Singapore. India is a recent entrant into medical tourism. According to a study by McKinsey and the Confederation of Indian Industry, medical tourism in India could become a $1 billion business by 2012. The report predicts that: “By 2012, if medical tourism were to reach 25 per cent of revenues of private up-market players, up to Rs 10,000 crore will be added to the revenues of these players”. The Indian government predicts that India’s $17billion-a-year health-care industry could grow 13 per cent in each of the next six years, boosted by medical tourism, which industry watchers say is growing at 30 per cent annually.
In India, the Apollo group alone has so far treated 95,000 international patients, many of whom are of Indian origin. Apollo has been a forerunner in medical tourism in India and attracts patients from Southeast Asia, Africa, and the Middle East. The group has tied up with hospitals in Mauritius, Tanzania, Bangladesh and Yemen besides running a hospital in Sri Lanka, and managing a hospital in Dubai.
Another corporate group running a chain of hospitals, Escorts, claims it has doubled its number of overseas patients - from 675 in 2000 to nearly 1,200 this year. Recently, the Ruby Hospital in Kolkata signed a contract with the British insurance company, BUPA. The management hopes to get British patients from the queue in the National Health Services soon. Some estimates say that foreigners account for 10 to 12 per cent of all patients in top Mumbai hospitals despite roadblocks like poor aviation connectivity, poor road infrastructure and absence of uniform quality standards.
Analysts say that as many as 150,000 medical tourists came to India last year. However, the current market for medical tourism in India is mainly limited to patients from the Middle East and South Asian economies. Some
claim that the industry would flourish even without Western medical tourists. Afro-Asian people spend as much as $20 billion a year on health care outside their countries – Nigerians alone spend an estimated $1 billion a year. Most of this money would be spent in Europe and America, but it is hoped that this would now be increasingly directed to developing countries with advanced facilities.
Contribution to GNP
According to the World Travel and Tourism Council, India' s travel and tourism (T&T) industry is expected to contribute 2.1 percent to Gross Domestic Product in 2006 (INR 713.8 billion or US$16.3 billion). In the first half of the Annual Plan period of 2005-2006, the Ministry of Tourism has taken several initiatives in the field of infrastructure development and positioning Indian tourism as a major engine for economic growth. These include:
Emphasis for developing the existing and new destinations to worldclass standards. Improvement of connectivity to important destinations.
Identification of 10-15 new destinations / circuits by each state /
UT for development to world class standard with all the required infrastructure components.
Benefits of Medical Tourism
Foreign exchange earrings which enable economic wealth of nation · · · · · Cost Advantage in Tariff over the Developed countries Improve information sharing Increase in efficiency of patient care process, cutting edge treatment. Improvement in hospital supply chain efficiency Strategic alliances with business partners within and outside the
country · · · · Technology and Knowledge Transfer Better logistics performance both in internal and external Creation of employment opportunities in the industry Better utilization of Infrastructure and skilled manpower
Opportunity for development in Infrastructure in Health, Tourism and
Travel. · · Economies of scale. Connectivity with air, road, rail and information and communication
industries · · Clustering of medical Travelers Health opportunities for foreign patients may lead to better standards at
home. · Scope for Research and Development to offer comprehensive medical
· · · · · · ·
International acceptance of country as a global healthcare provider Social and cross cultural experience International customer relations Global Marketing and Medical Trade relations Brand image of nation as world-class healthcare destination. Competitive advantage Better coordination among the partners i.e. hospital and hospitality
Public and Private Partnerships Patient satisfaction
Is India prepared for global medical tourism boom? In recent years, India is being seen as an important player in the globally growing "Medical Tourism", which is projected as a new segment in travel and healthcare business. "Global health destination" . In simple words, medical tourism provides state-of-the-art private medical care in collaboration with tourism industry to patients from other countries at highly competitive price when compared to those prevalent in the western countries. The CII- McKinsey report mentions that the medical tourism market has been growing at the rate of 15 per cent for past five years and by 2012, Rs 10,000 crore will be added to revenues of the private players. Globally, medical tourism is said to be USD 40 billion industry and analysis available project that people from Afro-Asian countries spend as much as USD 20 billion every year on healthcare services from outside their countries.
Foremost, amongst the current private players, in medical tourism are hospitals in the Apollo chain. Main destinations are Delhi, Mumbai, Chennai, Bangalore and Hyderabad. These cities have private hospitals with medical expertise that can offer world class healthcare that costs one fifth to one tenth of the cost in US or Europe depending on the intervention required. In addition to above destinations, the country has many cities with advanced medical facilities making India, a country with tremendous potential to capitalise on to increase its earnings to more than USD 1 billion annually and create hundreds of thousands new jobs in many sectors. This projection excludes earnings from other products included in the wellness tourism meant for rejuvenation of body and mind, eg herbal therapy, naturopathy, yoga, aromatherapy, reiki, music therapy which does not require advanced medical expertise. The apprehensions expressed by some sections that "systematic development of medical tourism will boost up earnings by catering to the wealthy foreigners and Indians working in the foreign countries but it may adversely hit the low income population" need to be addressed for gaining approval of political opinions with varied views on liberalisation. From past ten years,
India has entered a phase in medical expertise that is considered on par with international standards. This is because of high quality doctors and medical entrepreneurs who developed hospitals with required infrastructure and management style. Some of these hospitals have marketing departments to increase visibility and acceptance of their products in some countries.
Medical Tourism in India – The Current Scenario
Medical Tourism is poised to be the next Indian success story after Information Technology. According to a Mckinsey-CII study the industry’s earning potential estimated at Rs.5000-10000 Crores by 2012. Worldwide, healthcare is said to be a $3-trillion industry, and India is in a position to tap the top-end segment by highlighting its facilities and services, and exploiting the brand equity of leading Indian healthcare professionals across the globe.
“Medical Tourism", the term refers to the increasing tendency among people from the UK, the USA and many other third world countries, where medical services are either very expensive or not available, to leave their
countries in search for more affordable health options, often packaged with tourist attractions.
Tourism is an integral part of many economies’ services industry and is an important source of foreign exchange. The labour-intensive nature of the tourism industry also makes it an excellent generator of employment. In 2002, the travel-and-tourism industry is expected to generate some US$3.3 trillion of GDP and almost 200 million jobs across the world economy. Approximately one third of this would come directly from the industry itself and the remainder from the strong linkages to other related sectors such as entertainment, retail and construction.
Medical Tourism is perceived as one of the fastest growing segments in marketing ‘Destination India’ today. The equation is ‘ World Class Healthcare ’ at 'Economical Price '. Stable economic growth will create an increase in freight flows from, towards, through, and inside the country. All this will stimulate the investments in roads and railroads. As globalization advances, both domestic and international tourism pose new and unprecedented challenges to the health sector and its various partners. The
size of the Medical Tourism industry stands between Rs 1200 Crore to Rs 1500 Crore and is growing at rate of 30 percent annually.
More importantly, Medical Tourism is growing rapidly and turning out to be an immense business opportunity for nations that are positioning themselves correctly. Last year, just five countries in Asia – Thailand, Malaysia, Jordan, Singapore and India- pulled in over 1.3 million medical travelers and earned over $1billion (in treatment costs alone). In each of these nations, medical travel spends are growing at 20% plus year-on-year. Elsewhere around the world, Hong Kong, Lithuania and South Africa are emerging as big medical/healthcare destinations. And a dozen other nations including Croatia and Greece plan to make themselves attractive healthcare destinations.
Five years ago, hardly 10000 foreign patients visited India for medical treatment. Today India is a key player in medical tourism with 100,000 foreign patients coming in every year and revenue of Rs.1500 Crores. The current market growth-rate is around 30% per year and the country is inching closer to major players like Singapore and Thailand.
The following sections discuss in detail the current state of the Medical Tourism in India:
India’s Medical Infrastructure
15000 Hospitals 875000 Hospital Beds 500000 Doctors 737000 Nurses 170 Medical Colleges 350000 Pharmacies
3.6 Health Tourism In India – Advantages and Opportunities
•The inflow of health tourists from the West, especially the UK, US and some of the European countries has been on the rise for the last couple of
years. Price difference or affordability of the treatment, coupled
quality of doctors are the main reasons for the growing western traffic .
• The quality of Indian hospitals has improved significantly and now matches with the best in any part of the world. India has more than 100 healthcare institutions, which are of international standard.
• Many hospitals in India today have the infrastructure and equipment that match with the best centers in the world, be it
transplantations(liver/kidney/heart or bone marrow), cancer treatment, including radiotherapy, neurosurgery, including angioplasty and cardiac surgery(bypass and paediatric) sterotactic surgery.,
• Public-Private Partnership combines internal hospital expertise with supply chain and logistics expertise.
• The medical tourism industry which is estimated to be worth Rs 1500 crores annually has not only the potential to generate substantial forex pool of
earnings but also provide employment opportunities for the large
skilled labor available in India, Apollo Hospitals Group,
according to Dr. PC Reddy, chairman,
• According to Group President Pratap C.Reddy, the annual health bill of people from Afro-Asian countries seeking treatment outside their country
is $10 billion. If India can tap even a fraction of that market, the potential is enormous. Joint Commission Accreditation of Healthcare Organizations (JCAHO)
India - Strategic Thrusts for the Future
The following section lays down the strategy for India to achieve leadership position in medical tourism. The strategy largely draws from the discussions in previous section.
5.1 Role of Government
The role of Indian Government for success in medical tourism is two-fold: Acting as a Regulator to institute a uniform grading and accreditation system for hospitals to build consumers’ trust.
Acting as a Facilitator for encouraging private investment in medical infrastructure and policy-making for improving medical tourism. For facilitating investment the policy recommendations include: 1. Recognize healthcare as an infrastructure sector, and extend the benefits under sec 80-IA of the IT Act. Benefits include tax holidays for five years and concessional taxation for subsequent five years. 2. The government should actively promote FDI in healthcare sector. 3. Conducive fiscal policies - providing low interest rate loans, reducing import/excise duty for medical equipment 4. Facilitating clearances and certification like medical registration number, anti-pollution certificate etc. The above measures will kick-start hospital financing, which is struggling now due to capital intensive and low efficiency nature of healthcare business. For facilitating tourism the government should: 1. Reduce hassles in visa process and institute visa-on-arrival for patients 2. Follow an Open-Sky policy to increase inflow of flights into India 3. Create Medical Attachés to Indian embassies that promote health services to prospective Indian visitors
Formation of National Association of Health Tourism (NHAT)
The promotion of medical tourism has so far been very fragmented with initiatives by few states and private hospitals. The earlier discussions clearly underline the need for presence of an apex body that can coordinate the promotion of medical tourism abroad. In the Indian context too, this has been successfully demonstrated in the software industry by NASSCOM. It is therefore essential to form an apex body for health tourism – NAHT. The NAHT should be formed as an association of the private hospitals operating in the industry. The main agenda for NAHT will be:
1. Building the India Brand Abroad: Classify the target consumer segments based on their attractiveness and position the India Brand based on the three main value propositions – high quality service, value for money and
destination diversity. An integrated marketing Communications campaign using print, media and road shows should be developed.
2. Promoting Inter-Sectoral Coordination: The NAHT should take up the responsibility of aligning the activities of various players – Tourism Department, Transport Operators, Hotel Associations, Escorts personnel etc.
3. Information Dissemination using Technology: NAHT should set up a portal on medical tourism in India targeted at sharing information and enabling online transactions.
4. Standardization of Services: NAHT should also focus on establishing price parity for similar kinds of treatments in various hospitals and ensure the hospitals adhere to high hygiene and quality standards.
Role of Private Sector
The action items for private sector are: 1. Increased participation in building infrastructure: To achieve its full potential, it is estimated that India needs an investment of Rs.100000 to
140000 Crores by 2012. Since the government can afford only a third of the amount, the private sector should play an active role to fill the gap.
2. Integrate Horizontally: Private hospitals should also plan to integrate horizontally for providing end-to-end healthcare solutions to consumers. For example Apollo multi specialty hospitals is already planning to set up spas and alternative mediclinics to attract more foreign tourists.
3. Joint Ventures / Alliances: To counter increasing competition, Indian hospitals should tie-up with foreign institutions for assured supply of medical tourists. Specifically tie-ups with capacity constrained hospitals and insurance providers will provide significant competitive advantage.
5.4 Value Innovation Through MEDICITIES Another successful example of the software industry is the establishment of Export Oriented Software Technology Parks. This model can be successfully replicated in the medical tourism industry by means of MEDICITIES. Each MEDICITY could be a self-sustained healthcare hub with super specialty
hospitals of international standards, ancillary facilities, research institutions, health resort, rehabilitation centers and residential apartments. This model can be floated through a public-private partnership. The government will provide land and ancillary services and the private players will provide infrastructure and services. From the consumer’s point of view, the MEDICITIES will offer superior value at affordable prices. From industry’s point of view, this will offer significant competitive advantage for India.
The cartoon strip adds sarcasm to the upcoming medical tourism in India.
To study the feasibility of Medical Tourism in Delhi and NCR.
To compare the
performance of four hospitals in the region in
selected operations on the basis of following
i. ii. iii. iv. v.
Cost Value added services Popular operations Promotional activities Approachability
To Analyze trends Indian medical and healthcare Industry.
RESERCH DESIGN The research will be qualitative in nature as a lot of data is required to back the conclusion of the report.
DATA COLLECTION SOURCESThis study proposes to collect data from the Primary as well as the Secondary Sources. PRIMARY DATA Data collection tools like questionnaires have been used and also personal interview with the executives and surgeons of hospital like Apollo,Fortis,Escorts,Max Hospital were conducted to get detailed
information. Interaction with foreign tourist also helped in quantifying various services provided by the Hospitals and the Indian Tourism Board.
SECONDARY DATA Various sources like internet, Medical Journals, Magazines, Newspapers have been used to collect Secondary data.
SAMPLE SIZE The sample size taken for the study is four hospitals which have been chosen selectively namely FORTIS APOLLO MAX HEALTHCARE ESCORTS LIMITATIONS OF THE STUDY The study was restricted due to the following points
Denial to disclosure of authorities.
exact statistical data by the concerned
Also one of the most renowned hospital in India AIIMS denied to disclose any figures about medical tourism . Overall selection of 4 – 6 operations restricted the study. Locating less number of foreigner medical tourist around. Foreign tourist not in a state to interact as they come to India for major operations. Lack of journals. availability of empirical data on internet and medical
• • •
PARAMETERS AND CRITERIA FOR THE VIABILITY OF THE PROJECT The above mentioned hospitals were evaluated on the basis of following operations and surgeries namely
• • • • • •
HEART SURGERY(Intervention cardiology KIDNEY TRANSPLANT LIVER TRANSPLANT ORTHOPEDIC SURGERY(Knee replacement) PLASTIES NEURO SURGERY
• • • • •
Cost and value added offerings. After care amenities. Promotional activities done by the hospitals. Packages offered by hospitals Foreigners visiting there hospital.
MARKET VIABILITY OF INDIAN HEALTHCARE INDUSTRY
The Indian consumers can be assessed or segmented as per the following parameters..
Market Segmentation A market is composed of different users having different responses to market offerings. This makes it essential that hospital organizations, especially for making a microscopic study of users’ needs and requirement, make possible grouping of markets. The marketing strategy formulated on the basis for segmenting the market is income. To some extent regional considerations may also be adopted as a base for segmenting the market. The below is the segmentation on the basis of regional consideration:
Educated Illiterate Poor Rich
Educated Illiterate Poor Rich
The aforesaid segmentation makes it clear that doctors would find a variation in the living habits of both the segments. Another important base for segmenting hospital services may be income group. This helps hospital organisations in identifying the status of the users of services. It is essential as the marketing principles recommend different pricing strategies on the basis of level of income.
Low - Income
This would help hospital organisations in charging more from high and middle income groups, charging equal to cost from the low income group and making available free services to the no – income group. Another important advantage of this segmentation is concerned with implementation of modernization and expansion plan for the hospitals. THE MARKETING MIX OF INDIAN MEDICAL TOURISM
PRODUCTSome of the exclusive medical packages offered by the Indian
medical tourism are in the folowing treatments MEDICAL PACKAGES • HEART PACKAGES
CARDIAC SURGERY AND CARDIOLOGY ANGIOPLASTY ANGIOGRAPHY CARDIOLOGY ROBOTIC SURGERY OPEN HEART SURGERY PAEDIATRIC INTERVENTION • ORTHOPAEDIC SURGERIES JOINT KNEE REPLACEMENT(UNILATERAL AND BILATERAL • NEURO SURGERY PARKINSONS EPILEPSY ESSENTIAL TREMORS MALIGNANT TUMORS • CARDIOLOGY ECG DOPPLER TEST TEE BEATING HEART SURGERY VALVE SURGERY STENTING PERIPHERAL VASCULAR SURGERY CONGENITIAL HEART DISEASE • NEPHROLOGY DIALYSIS HAEMODIALYSIS SLOW CONTINOUS ULTRAFICATION
PLASMAPHERISIS • DENTAL CARE PACKAGES • UROLOGY • COSMETIC TREATMENT ETC
PRICE The price range offered by the Indian medical industry are unbelievable because india offers the most reasonable prices.. India is not only cheaper but the waiting time is almost nil. This is due to the outburst of the private sector which comprises of hospitals and clinics with the latest technology and best practitioners. Procedure Charges in India & USA –
United India (USD) States (USD) Approx Approx
Bone Marrow Transplant
Liver Transplant USD 3,00,000
USD 30,000 USD 8,700
USD 20,000 USD 6,300
Cataract Surgery USD 2,000
Smile Designing USD 8,000
Metal Free Bridge
Dental Implants USD 3,500
Porcelain Metal USD 3,000 Bridge
Porcelain Metal USD 1,000 Crown
Root Canal Treatment
Tooth WhiteningUSD 800
Tooth Colored Composite
Fillings / Tooth USD 300 Cleaning
Significant cost differences exist between U.K. and India when it comes to medical treatment. Accompanied with the cost are waiting times which exist in U.K. for patients which range from 3 months to over months.
Procedure Open Heart Surgery Cranio-Facial surgery and skull base Neuro- surgery with Hypothermia Complex spine surgery with implants Simple Spine Surgery
United Kingdom India (USD) (USD) Approx Approx USD 18,000 USD 13,000 USD 21,000 USD 13,000 USD 6,500 USD 4,800 USD 4,500 USD 6,800 USD 4,600 USD 2,300
Simple Brain USD 4,300 Tumor -Biopsy USD 10,000 -Surgery Parkinsons USD 6,500 Lesion USD 26,000 DBS Hip Replacement USD 13,000
USD1,200 USD 4,600 USD 2,300 USD 17,800 USD 4,500
• PLACE All the hi tech hospitals like Apollo, escorts, max hospitals are located in all the metro cities of the country and they are targeting the tier 2 cities due to the extreme market potential. Indian healthcare industry is the second in the country as its growing by leaps and bounds so the Indian hospital industry is getting organized.
• PROMOTION First and foremost it suggests that medical expertise in India is at par with the developed world although the infrastructure to support it is sadly lacking. This is the fact experienced by almost all Indian doctors who come to seek work in the Western World. PROMOTIONAL ACTIVITIES TO PROMOTE MEDICAL TOURISM • CME ( Continuous medical education for doctors) • Patient Education Progress • Free health Checkup camps.
• Tie ups with various hospitals and insurance companies abroad. • Participation in Health Expo’s abroad. • Tie ups Embassies. • AD campaigns. • Nodal centers in other countries. • Reduction of Excise duty from 17% to 8% on all goods produced in the pharmaceutical sector as per the Budget 2008-2009.
DEMAND FORECASTIncreasing globalization with reduction of travel times combined with added tourist attractions puts India in a good position to promote Health Tourism. India’s population crossed one billion in 1999 and is projected to exceed 1.5 billion in 2050. The infant mortality rate though having decreased from 225250 in the 1940’s to 72 in 1997, is still high. Mortality from Tuberculosis and Acquired Immune Defeciency Syndrome are major problems.(3) There is always the chance of the poor being exploited by unscrupulous element’s for purposes such as organ transplantation though trade in organs is illegal in India.(4) The CII-McKinsey report suggests that medical tourism could fetch as much as $2 billion by 2012, compared to an estimated $333 million currently. Reference: .Mudur G. Hospitals in India woo foreign patients. BMJ 2004; 328:1338.
HEALTHCARE INFRASTRUCTURE • India needs at least 750,000 extra beds to meet the demand for inpatient treatment by 2012- opportunity in tertiary healthcare facilities. • India needs at least 1 million more qualified nurses and 500,000 more doctors by 2012 as compared to existing number.- opportunity in medical education. • To raise this infrastructure, total additional investment to the tune of US$ 25-30 billion is needed by 2012. • Government and international agencies will only be able to gear up US$ 7 billion and the rest of investment has to come from private sector.
• FACTORS ENHANCING MEDICAL TOURISM IN INDIA
Cost Competitiveness – The Key driver The main reason for India’s emergence as a preferred destination is the inherent advantage of its healthcare industry. Today Indian healthcare is perceived to be
on par with global standards. Some of the top Indian hospitals and doctors have strong international reputation. But the most important factor that drives medical tourism to India is its low cost advantage. Majority of foreign patients visit India primarily to avail of “First World Service at Third World Cost”.
Source: Business World India and Indian Brand Equity Foundation As the table above shows, India has significant cost advantages in several health procedures making it a preferred destination
3.2 The Service Spectrum
India offers a variety of services for overseas patients. The table below presents a classification of the service spectrum.
3.3 Consumer Profile The demand for Indian healthcare services primarily comes from three types of consumers. The table below presents the profile of these three consumer groups:
Though tourism is not the primary need of these consumers, it offers additional attraction particularly for people traveling for cosmetic surgery and less complicated procedures.
HISTORY OF HOSPITALS APOLLO HOSPITAL Apollo Hospitals Group is the acknowledged leader in bringing super speciality world-class healthcare to India. It is presently the largest integrated healthcare company in Asia and the first to attract foreign investment .
Indraprastha Apollo Hospitals is spread over 12 acres of land and has a built-up area of 600,000 square feet. A joint venture between the Apollo Hospitals Group and the Government of Delhi, it was founded in 1996. It is the largest hospital of the group and was built at a cost of 44 million US dollars. With a bed-capacity of 560 (including 140 ICU beds and 44 HDU beds) and 14 Operation Theatres, expert medical professionals and the latest technology, the Indraprastha Apollo Hospitals is the automatic choice for outstanding healthcare in the country’s capital. The hospital handles close to 200,000 patients a year, of which 12,000 are international patients. International patients come to Indraprastha Apollo from the USA, UK, Europe, Middle East, Australia, Yemen, Africa and CIS countries, among other countries. Indraprastha Apollo Hospitals was the first Indian hospital to be awarded the gold-standard certification from the Joint Commission International (JCI) USA . Highlights
The first Indian hospital to receive the Joint Commission International (JCI) USA accreditation the gold-standard in hospital certifications worldwide First successful liver-kidney transplant in the Indian sub-continent Grade A by CRISIL Rated Best Multi-speciality Private Hospital in Delhi by The Week magazine BS EN ISO 14001: 1996 for Environmental Management System BS EN ISO 9001: 2000 for Quality Management System
• • •
One of India's leading tertiary level healthcare groups, Fortis Healthcare comprises a network of 13 hospitals with a bed capacity of 1803 beds and 13 Heart Command Centres. Following the acquisition of the renowned Escorts Healthcare System, Fortis Healthcare operates one of the world's largest Cardiac programmes. The group's Fortis Hospital at Noida, next-door to Delhi, is India's foremost tertiary care facility in Orthopaedics and Neuro Sciences. The group also performs cutting edge surgeries in various specialities ranging from cosmetology, woman & child health, ophthalmology, dental, ENT, urology, and minimal invasive surgery. Our facilities ensure that there is genuine Medical Value in health travel to India. The Medical Value that we bring to our services is because the Fortis Healthcare team of expert doctors, mostly western trained, is supported by highly skilled nursing professionals, technicians,and aided by state-of-theart medical equipment at their command. At Fortis Healthcare, we recognize that international patients have special needs and requirements and desire real medical value when they travel to India. To provide a highly specialized and dedicated service, we have created the Fortis Healthcare international Patients Service Centre at New Delhi, India. Various medical specialties offered to our International patients are:
Cardiology Cardio Thoracic & Vascular Surgery Orthopaedics Orthopaedic Surgery (Total Hip/Knee Replacements, Joint Replacements) Plastic Surgery Cosmetic Surgery Bariatric Surgery (Gastric By Pass Surgery, Gastric Banding etc) Gynaecology & Obstetrics General Sugery
Minimal Invasive Surgery Neurology & Neuro Surgery Nephrology (Dialysis) Paediatrics & Paediatric Surgery Pulmonology Renal Sciences (Renal Transplantation) ENT Opthalmology (Eye) Psychiatry
For you, this means a menu of seamless services that will make your treatment and trip hassle-free, i.e. from greeting you at the airport, to your registration & discharge, and even organizing the ground handling of any post-treatment travel. After all, taking care of guests is an ageless Indian tradition.
SPECIAL SERVICES(VALUE ADDED SERVICES)
• • • • • • • • • • •
Doctor care coordination Before and after Airport transfer Service. Flight Arrangements & Extensions / Visa Assistance. Coordination of the admissions process. Cost estimates for anticipated treatment. Booking of Hotel/Service Apartments. Special dietary needs / religious arrangements. Providing news & information of patient's relatives back home. Remote Consultations via Telemedicine. Remote Consultations via Telemedicine. Financial Services.
Overview - Max Healthcare - caring for you…for life
Max Healthcare is India's first truly integrated healthcare system, offering three levels of clinical service (Primary, Secondary, Tertiary) within one system. We believe in the concept of total patient care and deliver care by combining medical and service excellence. Max Healthcare is committed to quality care that not only addresses the illness but also concentrates on the overall wellness of the patients
• • • • • • •
A team of highly qualified and trained doctors, nurses and patient care personnel to provide the highest standards of care Latest medical equipment and hospital information system Medical collaboration with Singapore General Hospital in areas of medical practices, research and training Over 400 leading doctors, 280 corporate clients and a patient base in excess of 5,80,000 Clean and comfortable facilities at all locations Fully computerised health records 24 hour- Chemist, Ambulance, Patient Diagnostic and Emergency Services
• • • •
Regular educational and health camps to help educate patients on various health issues, so that they make informed choices Max Happy Family Plan- Annual Health Plans covering domiciliary medical needs A complete preventive healthcare programme - MAX 360° 24 Hour Emergency
Comprehensive Healthcare System Max Healthcare model visualizes setting up of a world-class healthcare model offering the best medical assistance delivered seamlessly through state-of-the-art medical facilities.
NO SPECIAL SERVICES FOR INTERNATIONAL PATIENTS, ALL THE PATIENTS ARE SAME FOR THEM.
Welcome to the comforting world of Escorts Heart Institute and Research Centre, where the medical treatment is truly world-class and our approach towards our patient is warm and sensitive. We Assure, that you are in trusted hands and your journey, will be a pleasant one. Escorts Heart Institute & Research Centre (EHIRC), was born to bring to India the best cardiac care and systems, training of cardiac surgeons and cardiologists and to conduct research as per International standards. It has
completed 20 years of excellence in providing highest standards of cardiac care in India. .
Centres of Excellence
• • • • •
Cardiac Bypass Surgery Minimally Invasive Surgery (Robotics) Interventional Cardiology Non-invasive Cardiology Pediatric Cardiology
• • • • • • •
20 years of Cardiac Care Hospital has 332 Beds, 9 Operation Theatres, 5 Cath Labs, 3 Heart Command Centres, 2 Heart Stations Done Over 114,700 Angiographies Over 27,000 Angioplasties Completed Over 65,000 Cardiac Surgical Procedures Success rate of Cardiac Procedures is 99.6% Infection Rate of less than 0.3%
The Infrastructure of Excellence Escorts Heart Institute is equipped with modern facilities, equipment and systems like:
• • • • •
Operation Theatres (OTs) with Laminar air flow that eliminates the chances of infection Intensive Care Units (ICUs), under the charge of critical care specialist that has a ratio of one nurse for every ICU patient High-tech systems for Imaging, Radiology and Pathology Testing Sophisticated Information Technology systems at Escorts Hospital enable better efficiency and greater patient convenience Convenient support facilities such as: ATMs, Cafeterias, Round the clock Pharmacy
International Patient Care
Patient safety is our top priority, Escorts recognizes that international patients have special needs and requirements. Escorts offers seamless patient services of world-class quality. From the warmth of our greeting at the airport, to your registration and discharge, we strive to deliver unparallel services to aid you. All services are provided to International patients through a single window assistance cell, from arrival till departure. The activities related to this important area of our business are: 1. Visa Assistance
Coordination and Liaising with Foreign Offices.
2. Medical Needs
• • • • •
Arranging meeting on priority with the concerned Consultant. Arranging any specific medical needs, while traveling to New Delhi. Smooth discharge procedure under single window. Medical certificates/reports. Follow up visits/tests/reports.
3. Lodging/Boarding Arrangements
• • •
Lodging the patient/attendant in EHIRC/Hotel/Guest House. Diet requirement as per patient needs. Regular supervision of all lodging facilities.
4. Information Needs
• • •
EHIRC Brochures/Information. Delhi City Map /City Guide. Providing news & information of patient to their relatives, back home.
5. Value Added Services
• • • • •
Dedicated Patient care coordinators to assist Patient/Attendant. Travel/ticketing arrangements for patients and relatives. Receive the patient from Airport - Car/Ambulance. Arranging sight seeing / shopping / prayer. Local travel needs for patient's relatives.
• • • • • •
Prepaid Cell phone Card. Interpreters. Internet. Comprehensive Health Check Ups. Foreign Exchange. All finance related matters under single window.
6. Our insurance partnerships
• • • • • •
BUPA International AETNA CIGNA International SOS Vanbreda International GMC Services
ANALYSIS AND INTREPRETATION
As per the data collected from the four hospitals • GRAPH1
Apollo-3000 Fortis-36 Escorts-240 Max hospital-1000 Total international patients coming to India4276
• GRAPH 2
PREFFERED SURGERIES BY INTERNATIONAL TOURIST
45% PERCENTAGE VALUE 40% 35% 30% 25% 20% 15% 10% 5% 0% TYPES OF SURGERIES 8% 15% 5% 40% 32%
Heart surgeryNeuro surgeryOrthopedic surgeryNephro surgeriesLiver transplant-
• • • • •
Heart surgery- 40% Neuro surgery- 8% Orthopedic surgery-15 Nephro surgeries-32% Liver transplant-5%
• GRAPH 3
Investment required to bridge the gap in next 10 years
Medical equipment could account for 2030% of investment in Beds (Rs.20,000 to 40,000 crore)
Investment Investment Investment in secondary in tertiary in medical beds colleges* beds
Investment Investment Total in nursing for other investment health professionalsrequired schools (e.g., pharmacists, technicians, administrators)
* Excludes investment in bed capacity to avoid double count with investment in secondary/tertiary beds (Source: CII-McKinsey & Company Report 2005)
Escorts Heart Institute & Research Centre Ltd,
PROMOTIONAL ACTIVITIES DONE BY HOSPITALS TO ENHANCE MEDICAL TOURISM
INDRAPRASTHA APOLLO Attending World Travel Marts and World Medical Fairs.
ESCORTS HOSPITAL Tie ups with various agencies abroad involved in medical tourism. Participation in Health Expos in UK. Ad campaign for India.
FORTIS HOSPITAL Conduct CME(continuous Medical Education for doctors), Free health checkups for doctors, On campus patient education programmes,Ad campaign Dhakan on TV.
MAX HOSPITAL Tie up with most of the embassies ,free cardiac camps in various countries, CME, Nodal centers in UK,US etc. Hospitals in gulf countries, Tie ups with most of the insurance companies.
Comparison - India Vs other countries
Beds Physicians Nurses Per ’000 population, 2006*
Per ’000 population, 2006* India
Per ’000 population, 2006* 0.5** 1.2***
Other low income countries (e.g., sub-Saharan Africa) Middle income countries (e.g., China, Brazil Thailand, South Africa, Korea) High income countries (e.g., US, Western Europe, Japan) World average
• GRAPH 6
Comparison India Vs other countries
Healthcare spend as % of GDP
Per cent, 2006*
Healthcare spend per capita
US$, PPP, 2006*
* Most recent data available has been used (2001-2006)
After the analysis and interpretation of the data we can figure out the following
Graph 1(Total international patients coming to India) We can witness that majority of the international patient
Prefer Indraprastha Apollo at the first place followed by Max hospital, Escorts and only a minority of them prefer Fortis
GRAPH2 (Preferred surgeries by international tourists)
It very clearly depicts that majority of the tourist consider India (Delhi) as a destination for heart surgery followed by Nephro surgeries(kidney related problems) then orthopedic, Neuro and only a fraction of them come for kidney transplants.
GRAPH 3(Investment required to bridge the gap in next 10 years )
The graph clearly states that if proper investment will be made then India will be at the top level in the healthcare industry. The graph shows in what ratios the investment should be done like on mediacal equipment could account for 20-30% of investment in beds.
GRAPH 4 ( Cost advantage and list of various medical services) It tells us about the various services offered under the umbrella of Indian medical tourism and also the price comparison of dental treatments and surgeries in India and US for eg getting a Glass Ceramic Crown fitted in India would cost 35-40% less in India than US.
GRAPH 5 (Comparison - India Vs other countries) This graph clearly shows the comparison of India with the other low, middle and high level income countries in terms of beds, physicians and nurses with the relation of per thousand populations in year 2006.
GRAPH 6 (Comparison - India Vs other countries)
This graph clearly shows the comparison of India with the other countries in terms of healthcare spend as percent of GDP and healthcare spends per capita respectively in year 2006.
Medical Tourism in Delhi and NCR as per the study conducted is booming and can be witnessed by the huge number of International tourist visiting this region. Delhi and NCR is one of the worlds most preferred region of the world in the case of medical tourism due to the low cost of treatment, no waiting time, approachability, tourists spots in delhi and nearby cities and other value added services. As the Indian economy of growing so worlds best hospitals are coming to India to encash the opportunity.
Another relevant topic that has been
covered in the study is the in attracting the
performance of four hospitals in the region and it can be concluded that indraprastha Apollo is the market leader maximum no of international patients because of the brand name Apollo and its presence in various other countries. Apollo is followed by Max which is considered as a five star hospital caters to patients falling in the high income bracket followed by Escorts and Fortis.
Also the trends in the Indian Healthcare has been studied and it can be concluded that the healthcare industry has successfully managed to maintain the interest and attention of not only the Indian government, but also the common man.
The top Indian hospitals such as Apollo, Escorts, Max, etc, are investing immense time, effort, manpower and money in their R&D.
As a matter of fact, several new innovative products have been launched in the Indian market and have been patented. The Indian consumer has ready access to new innovations in the field of health and medicine. The companies are constantly acquiring latest technology either through partnerships or developing them indigenously. The government is fully supporting the cause of state of the art infrastructure by providing support in setting up new hospitals and financing them.
All the hospitals in the region should accentuate on promotional activities at the global level so as to enhance the awareness of medical proficiencies in India. Other government hospitals should also try to meet international standards. The government should pass an act according to which the fee structure of various medical colleges should be reduced so as to facilitate and motivate lower and middle class students. The government should also come up with various medical colleges in different parts of the country. This will help India to cope up with the increasing demand of medical tourism locally and internationally.
Create cost-effective facilities
To deliver quality healthcare to a greater number of people, providers must create and operate more cost-effective facilities. Optimizing
parameters such as area per bed and building cost per square foot can reduce the initial cost of building a tertiary facility. In addition, operating costs can be reduced through better purchasing and supply chain management, as well as good management of patient flows and utilization of expensive facilities and manpower.
An active industry association can play an important role in the development of the sector
To boost the overall growth and development of healthcare in India, the sector needs a vibrant industry association. This need can be met by the Indian Healthcare Federation (IHF), which will have to present a united face to key stakeholders such as the government, insurers, policy institutions and industry players. To be effective, the IHF will need a full-time team of professionals on board. There are three immediate priorities for the federation: driving the creation and adoption of quality and accreditation standards for healthcare infrastructure and delivery; working with insurers to accelerate the penetration of health insurance; and collaborating wit the government on policy issues. In addition, the federation should increase awareness about industry-level issues among industry participants.
CHAPTER 8 APPENDIX BIBLIOGRAPHY BOOKS
Author's last name, first name middle name; "Title of journal,” (year of publication) Davenport Karen, “Health Care Benefits”, (2007) Daschle Tom, “Achieving Universal Health Coverage”, (2007) Seshamani Meena, “Opportunity Costs and Opportunities Lost: Businesses Speak Out About Health Care”, (2007) CII and Mekinsey, “Healthcare In India – The Road Ahead”, (2006)
JOURNALS Author's last name, first name middle name; "Title of journal,” issue number: (year of publication) Alvarez, David P.; “Connecting people to the promise of healtchare”, No. 15 (2000) Hautea, Dr. Randy A.; Krattiger, Dr. Anatole F. And Van Zanten, Ir. Jasper E; “Healthcare costs comparisons”, No. 18 (2000)
WEBSITES <URL> http://en.wikipedia.org/wiki/Healthcare_in_India http://www.nature.com/nm/journal/v9/n4/full/nm0403-377a.html http://www.cbc.ca/news/background/healthcare/medicaltourism.html http://timesofindia.indiatimes.com/More_options_for_health_insurance/artic leshow/1982238.cms http://www.who.int/mediacentre/factsheets/fs172/en/index.html http://www.indiatogether.org/2007/jan/hlt-hltcare.htm http://www.deloitte.com/dtt/whitepaper/0,1017,sid%253D34239%2526cid %253D71669,00.html
1) Name of the Hospital- ________________________________ 2) Location- ____________________________________ ____________________________________ ____________________________________ ___________________________________
3) Person Concerned- __________________________________
4) Designation- ____________________________ 5) No of Foreigners visiting their Hospital Every Year/ Month- ________ 6) Medical Travelers Clusters Country Wisea) ___________________________ b) ___________________________ c) ___________________________ d) ___________________________ e) ____________________________ f) _____________________________
7) Surgeries or Treatments they specifically come for• • • • • • • Heart SurgeryKidney TransplantLiver TransplantBone Marrow TransplantOrthopedic SurgeryFace liftAny other-
8) Duration of their stay in India? ________________ 9) Various Packages offered by the hospital-
10) Promotional Activities done by the Hospital to enhance Medical Tourism-
11) Value added offerings to an international patient compared to an domestic patient.
__________________________________________________________ 12)Provisions for aftercare follow-ups ?