A PROJECT REPORT ON

MEDICAL TOURISM IN INDIA

SUBMITTED TO

UNIVERSITY OF MUMBAI

BY

GAURAV VIJAY CHHABRIA
T. Y. B.M.S.

YEAR 2005-2006

THROUGH

TOLANI COLLEGE OF COMMERCE
ANDHERI (EAST), MUMBAI – 400 093

CERTIFICATE

I, Dr. A. A. Rashid, hereby certify that Mr. Gaurav Chhabria of Tolani College of Commerce, T.Y. B.M.S. (Semester V) has completed his project titled Medical Tourism in India in the academic year 2005-2006. The information submitted herein is true and original to the best of my knowledge.

Dr. A. A. Rashid (Project Guide)

Dr. Sheela Purohit (Principal)

DECLARATION

I, Gaurav Chhabria, of Tolani College of Commerce, T.Y. B.M.S. (Semester V) hereby declare that I have completed my project titled Medical Tourism in India in the academic year 2005-2006. The information submitted herein is true and original to the best of my knowledge.

Place: MUMBAI Date:

Gaurav Chhabria

ACKNOWLEDGEMENT

I would like to acknowledge the following as being instrumental in the completion of this project:

First and foremost I would like to thank my guide, Dr. A. A. Rashid, whose invaluable support helped me compile this project.

I also availed of the Internet which is a source of vast, spontaneous and accurate information on the subject being researched.

Lastly I would like to acknowledge the support of my family and friends without whom the project wouldn’t have been a success.

I sincerely hope that the project lives up to your expectations.

INDEX

Sr. no. 1.

Topic Introduction - Why Medical Tourism? - Global Scenario - A Worldwide Market Medical Tourism as an Industry Growth of Medical Tourism The Indian healthcare situation Indian healthcare specialities Ancient Indian Therapy Health check-up Promotion of medical tourism Kerala-the pioneer state Karnataka’s foray into the health care sector Medical Tourism and public health services Different views on should public hospitals participate in medical tourism Medical Tourism in Metros & Suburban city (New Delhi, Mumbai, Pune) - Maharashtra’s unlimited potential Public survey & analysis Potential of India in area of medical tourism and steps taken Medical tourism may generate Rs.100 billion – Study Medical tourism is growing in smaller city Medical tourism to cure ailing inbound sector - FICCI’S focus on Medical Tourism - Medical Tourism - winning hearts overseas Case study New Emerging Destination of Medical Tourism other than India - Jordan the friendly neighbouring doctor - Thailand a makeover for the makeover expert - India far cheaper than Thailand Government launches medical tourism council Question straight Answer Conclusion - Counter plan (to tap medical tourism) Bibliography

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9 10 11 – 13 14 – 16 17 – 23 24 – 25 26 – 28 29 – 33 34 35 36 – 38 39 – 47

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48 – 49 50 – 51 52 – 54 55 – 56 57 – 58

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59 60 – 64

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65 66 – 67 68 71

INTRODUCTION
The most recent trend in privatization of health services is medical tourism, which is gaining prominence in developing countries. Globalization has promoted a consumerist culture, thereby promoting goods and services that can feed the aspirations arising from this culture. This has had its effect in the health sector too, with the emergence of a private sector that thrives by servicing a small percentage of the population that has the ability to “buy” medical care at the rates at which the “high end” of the private medical sector provides such care. This has changed the character of the medical care sector, with the entry of the corporate sector. Corporate run institutions are seized with the necessity to maximize profits and expand their coverage. These objectives face a constraint in the form of the relatively small size of the population in developing countries that can afford services offered by such institutions. In this background, corporate interests in the Medical Care sector are looking for opportunities that go beyond the limited domestic “market” for high cost medical care. This is the genesis of the “medical tourism” industry.

Health tourism is tipped to be next big-bucks business for India. Health care is a $3 trillion industry worldwide and India is in a position to tap the top-end segment by highlighting its state-of-art facilities and services, and exploiting the brand equity of leading Indian healthcare professionals across the globe.

The heart surgery of Pakistani baby Noor Fathima in Bangalore has once again turned the spotlight on Karnataka’s unique position as a centre for world class healthcare facilities, together with its equally fascinating tourist attractions, and spurred the state into a proactive mode to claim its share of the action.

As a part of this initiative, the Karnataka tourism department is leading a team of hospital officials to the Bahrain Global Health Summit to pitch for some attention from potential buyers of health tourism services. Four leading institutions – Wockhardt, Narayana Hruduyalaya, Sagar Apollo and Soukya have already participated, said VanditaSharma, commissioner tourism for Karnataka.

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According to state tourism and IT minister, DB Inamdar, world-class medical institutes in Karnataka carry out surgeries for half – in many cases for a third or fifth – of the cost in the west. More importantly appointments are available much quicker than in the US or the UK, where patients often face long waiting lists. There are also a clutch of good health and wellness clinics along with spa resorts, and great locations of tourist interest in the state, which can help position Karnataka as a leading health tourism destination.

The US, Canada, the UK, the Mid-East, and even Asian states like Sri Lanka are viewed as great markets for selling health tourism packages in Karnataka. Assistant director for Sri Lankan tourism, Madhubani periera, told ET that Lankan tour operates are already exploring the opportunity with medical centres in Bangalore. The success of the recently set us Apollo Hospital in the island is said to have egged travel companies to scout for fresh possibilities in Karnataka, since there are four direct weekly flights to Bangalore from Colombo.

Narayana Hruduyalaya’s Devi Shetty says tourism related to healthcare generates higher revenues than pure vacationers. Patients who visit Bangalore for treatment along with their families tend to stay longer than most tourists. Post-operation, family members often relax by visiting places of tourist interest. For instance, a person staying in the city for a heart surgery spends around Rs.2 lakh during a week-long halt, which is miles ahead of the expenditure incurred by a typical tourist.

Hospitality industry experts say there is another aspect of health tourism, pampering and wellness which is gathering momentum in the west and has been successfully packaged by Kerala. Leele palace Bangalore’s Eric Swanson explains that pampering involves offering people an experience – massages, herbal wraps and exfoliating scrubs – that makes them feel relaxed. Wellness involves helping healthy people stays well, both physically and mentally. Sometimes, this means offering diagnostic testing to identify potential problems. The West’s fascination with fitness and alternative therapies for health maintenance and healing is another factor. Spas for healthy people currently represent the lion’s share of the health tourism market in the west.

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New trendsetters have started arising on the horizon of the widespread global trade. One of these trendsetters, who is fast emerging and has an added value of making huge economical profits, is ‘Medical Tourism’. According to a research professor Rupa Chanda, IIM; Medical Tourism will single handedly fetch a very impressive amount of $4 trillion on a world-wide scale. The World Trade Organization studied the scope of this new found field. The study was conducted in Thailand, Malaysia, Jordan, Singapore & India, which resulted in the findings, that in these 5 countries the number of medical travelers in the year 2003 was almost 1.3 million and thus collectively earned almost $1 billion (in treatment cost alone). In case of these nations the medical travel spends are growing at the rate of 20% plus on a year-to-year basis. Now, let us know who could be the potential clients for Medical Tourism purposes. These medical travelers could be broadly classified into 4 distinct geographical groups. The first group of medical travelers is made up of Americans. The U.S. boasts of the best medical facilities in the world & that to instantly. But the value of these services offered is very high. Also the American healthcare system is pre-dominantly insurance driven which includes only critical care and not cosmetic care for and not cosmetic care for which a vast no. of American people are opting now including facelifts, liposuction, dental treatments, etc. Going by an estimate a full facelift in the U.S. costs $8000-20000, which costs only $1252 in South Africa. Thus Americans go in for he cosmetic surgeries that are available outside America in other countries like South Africa, Thailand, etc. that mean a vacation well. Given these increasing costs of medical treatments in the U.S. it makes sound economical sense to seek treatments abroad. The second major group is the people in UK. Unlike in the US the British healthcare system ensures free treatments to all its citizens. Yet the people are being forced to seek medical treatments in other countries by the sheer waiting lists caused by the National Health Service which we have seen in the introductory case of Mr. Cyril Parry. This is probably because of the shortage of doctors and hospital beds. Also private medical facilities here are prohibitively expensive and relatively fewer in

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number. These are the two major reasons why British patients take the initiative to seek their own treatments abroad. The third chunk of medical travelers comes from the Middle-East, where the people of these oil-rich nations fly abroad to seek medical facilities that are either unavailable or in short supply in their own countries. According to an estimate more than 5lakh people from the Middle-East travel abroad every year for Medical Treatments. They travel mainly to Jordan, Saudi Arabia, Bahrain, US, India, Thailand & Malaysia. By some estimate India itself attracted around 70,000 plus travelers from the Middle-East last year. The final lot includes people from the least developed nations traveling to their well developed neighbours. Last year it was estimated that nearly 50,000 people from Nepal and Bangladesh came for medical treatments to India. India is considered the leading country promoting medical tourism-and now it is moving into a new area of "medical outsourcing," where subcontractors provide services to the overburdened medical care systems in western countries. India's National Health Policy declares that treatment of foreign patients is legally an "export" and deemed "eligible for all fiscal incentives extended to export earnings." Government and private sector studies in India estimate that medical tourism could bring between $1 billion and $2 billion US into the country by 2012. The reports estimate that medical tourism to India is growing by 30 per cent a year. India's top-rated education system is not only churning out computer programmers and engineers, but an estimated 20,000 to 30,000 doctors and nurses each year. The largest of the estimated half-dozen medical corporations in India serving medical tourists is Apollo Hospital Enterprises, which treated an estimated 60,000 patients between 2001 and spring 2004. It is Apollo that is aggressively moving into medical outsourcing. Apollo already provides overnight computer services for U.S. insurance companies and hospitals as well as working with big pharmaceutical corporations with drug trials. Dr. Prathap C. Reddy, the chairman of the company, began negotiations in the spring of 2004 with Britain's National Health Service to work as a subcontractor, to do operations and medical tests for patients at a fraction of the cost in Britain for either government or private care.

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Apollo's business began to grow in the 1990s, with the deregulation of the Indian economy, which drastically cut the bureaucratic barriers to expansion and made it easier to import the most modern medical equipment. The first patients were Indian expatriate who returned home for treatment; major investment houses followed with money and then patients from Europe, the Middle East and Canada began to arrive. Apollo now has 37 hospitals, with about 7,000 beds. The company is in partnership in hospitals in Kuwait, SriLanka and Nigeria. Western patients usually get a package deal that includes flights, transfers, hotels, treatment and often a post-operative vacation. Apollo has also reacted to criticism by Indian politicians by expanding its services to India's millions of poor. It has set aside free beds for those who can't afford care, has set up a trust fund and is pioneering remote, satellite-linked telemedicine across India.

Why Medical Tourism?
Medical tourism - patients going to a different country for either urgent or elective medical procedures - is fast becoming a worldwide phenomenon. The reasons patients travel for treatment vary. Many medical tourists from the United States are looking for treatment at a fraction of the cost at home. Canadian and UK medical tourists are frustrated by long waiting times. Becoming a medical tourist also provides a chance to combine a tropical vacation with elective or plastic surgery, for others.

India's top-rated education system is not only churning out computer programmers and engineers, but an estimated 20,000 to 30,000 doctors and nurses each year. India is considered the leading country promoting medical tourism-and now it is moving into a new area of "medical outsourcing," where subcontractors provide services to the overburdened medical care systems in western countries. India's healthcare industry is growing at 30 per cent annually and could earn more than $1-2 billion annually, creating 40 million new jobs in the process, by 2012.

Today while we look up at the tourism sector the foremost thing that come to our mind are leisure tourism activities, adventure activities etc. but the sector of medical

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tourism remains unexplored and untapped. The sector has great potentialities in lending the tourism activities. The estimated Indian market alone at present amounts to almost $40 million approximately which suggest that there is even more value than the mentioned one and is yet to be tapped.

The reasons for which I selected Medical Tourism as my final topic for project are:• • • The Medical Tourism sector also known as the Healthcare sector still remains a toddler compared to the other sectors like leisure, adventure, pilgrims, etc. Medical Tourism will act as a boom for boosting the overall tourism sector in India. A well planned and promoted Indian healthcare sector as well as the coordinated efforts of the medical fraternity and the government of India will increase the standards of the healthcare in India. This in turn will be helpful to local population as well. • • • The traditional Indian ways of healing if promoted and publicized well could do wonders to the Indian economy. Along with the medical sector comes a very vital sector for free known as the insurance sector which can also support the Indian economy. Another issue was Indian becoming an important destination for various medical conferences which could improve the influx of the foreign tourists and in turn generate good amount of Forex.

Global Scenario
Nobody has collected the complete worldwide statistics about how many people travel abroad for health related reasons every year or how much they spend. But a Saudi Arabian report pointed out that in 2000, medical travelers from the gulf region alone spent over $27 billion seeking treatments in various countries around the world. If the medical travelers from around the world spent even half as much that year, the total business in 2000 alone would have been in excess of $40 billion and even that would be an underestimate.

The estimate is that the healthcare market in the organization of economic

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a cooperation and development country alone is worth about $3 trillion and is expected to rise up to $4 trillion in 2005.

More importantly, it is growing leaps and bounds and turning out to be an immense business opportunity for nations that are positioning themselves correctly. Last year just 5 countries in Asia (Thailand, Malaysia, Jordan, Singapore & India) pulled in over 1.3 million medical travelers and earned over $1 billion (in treatments alone). In each of these nations the medical travel spending are growing at a rate of 20% plus every year.

Elsewhere around the world Hong Kong, Lithuania and South Africa are emerging as big healthcare destinations and a dozen other nations like Croatia, Greece, etc. are planning to make it big in this sector.

By itself, traveling abroad for medical reasons is not a new phenomenon. Even in the ancient times people were used to travel abroad for the same. But in the past 5 years or so the movement has accelerated sharply. It has developed a massive momentum for two critical reasons.

The first being the demographics of the developed countries and also the problems associated with their healthcare sector. In the US, UK, Japan and many European countries majority of the population has either hit the retirement age or are heading towards it. Meanwhile the life expectancy rate has also grown steadily over the years. These two reasons add up to give a big surge in the demand of the healthcare.

Also there is a pull factor being created by a handful of developing countries like Thailand & Malaysia that have good doctors and excellent facilities and which are positioning themselves as medical destinations of the future in order to boost their economies. India is also joining this bandwagon.

Though the movement can still be considered to be in its infancy; medical travel has come under the radar of both the World Health Organization (WHO) and the World Trade Organization (WTO). Both these organizations understand that medical travel could ameliorate much of the demand-supply imbalance in global healthcare. ..7..

Developed nations could benefit in terms of costs or waiting time or both coming down significantly for a major chunk of the population. Developing countries benefit as it brings revenues, upgrades infrastructure for the locals and reduces brain drain in their medical fraternities. Least developed countries too benefit as they improve upon the facilities lacking for cutting edge treatment.

A Worldwide Market
What's called medical tourism – patients going to a different country for either urgent or elective medical procedures – is fast becoming a worldwide, multibillion-dollar industry.

The reasons patients travel for treatment vary. Many medical tourists from the United States are seeking treatment at a quarter or sometimes even a 10th of the cost at home. From Canada, it is often people who are frustrated by long waiting times. From Great Britain, the patient can't wait for treatment by the National Health Service but also can't afford to see a physician in private practice. For others, becoming a medical tourist is a chance to combine a tropical vacation with elective or plastic surgery.

And more patients are coming from poorer countries such as Bangladesh where treatment and may not be available.

Medical tourism is actually thousands of years old. In ancient Greece, pilgrims and patients came from all over the Mediterranean to the sanctuary of the healing god, Asklepios, at Epidaurus. In Roman Britain, patients took the waters at a shrine at Bath, a practice that continued for 2,000 years. From the 18th century wealthy Europeans travelled to spas from Germany to the Nile. In the 21st century, relatively low-cost jet travel has taken the industry beyond the wealthy and desperate. Countries that actively promote medical tourism include Cuba, Costa Rica, Hungary, India, Israel, Jordan, Lithuania, Malaysia and Thailand. Belgium, Poland and Singapore are now entering the field. South Africa specializes in medical safaris-visit the country for a safari, with a stopover for plastic surgery, a nose job and a chance to see lions and elephants.

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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 capitalize till ion 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.

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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 $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.

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 in the year 2004. 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.

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THE INDIAN HEALTHCARE SITUATION
Besides being the land of Taj, a land of diverse cultures, a land of tradition, a land of highly developed spiritualism, India can also be called the land of healing for the ailing.

Contemporary India is a forerunner in providing healthcare facilities for all kinds and type of patients. This has been possible largely because of the professionalism that has creped in to the healthcare sector. The credit for this goes wholly to the private sector. Also as a result of this the medical help in India is now comparable to the best in the world.

India provides a long list of various facilities like world class hospitals, state-of art technology, competent doctors, professional management, top quality nurse and paramedical staff and all this with an icing of comparatively lower prices making it economical as well. More and more people are realizing that India is the right place for top quality and economically affordable treatments. It is also reliable and can be regarded as one of the best in the world.

As far as India is concerned price factor is the major advantage. It has been taken into account that the cost of getting treated in India is almost 10% and in some cases 8090% cheaper than what it costs in the developed countries. This becomes very evident when you notice the average the Indian cost of a cardiac surgery and Compare it with the average US cost. This coupled with the fact that cardiac surgery in India has a success rate of 98.5% which is comparable to the best institutions in the world. This is certainly a major benefit.

Hospitals in the major metros of India have already recorded a 12% international patient flow. These patients are mainly from the neighboring South East Asian countries. And these figures will be growing in the near future.

India can catch up by the medical travelers for specific medical treatments as well as for regular medical check ups. Most of the hospitals are centrally located in the major Indian cities, are easily accessible and are capable of looking after the patients with

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best care. This was in regards with urban medi-care but rural India also runs back to back. It may not have world class infrastructure but the medical attention is prompt with competent doctors even in the remotest parts of the country.

For those who plan to get a regular medical check up done, India is the ideal the place to be. With its numerous attractions one can come here with the family and combine the health check up with a pleasure trip for the family.

All this is because of the enormous growth witnessed by the private sector. It was very modest in the early stages and has now become a flourishing industry with the most modern state-of-art technology at its disposal. It is estimated that 75-80% of the healthcare services and investments in India are now provided by the private sector.

An added advantage that India has is that it has one of the largest congregations of pharmaceutical companies in the whole world. It is self-sufficient in drug production and exports drugs to more than 180 countries.

The privatization of this sector has brought with it facilities of the star categories & world class treatments. The country now boasts a number of corporate hospitals. India is a market for professionals in the medical field for most of the renowned hospitals in the whole world. Hi-tech medical facilities have become a necessity following the consumer demand among the world’s fastest growing middle-class masses. India offers at its own doorsteps a range of world quality hospitals and treatments at a fraction of world costs with comparable success rate and service levels directly in proportion to the high value system and natural caring that comes along with its traditional heritage.

Indian hospitals are now being acclaimed the world over for the standards of healthcare delivery. The country boasts of superior technology with skilled super specialists along with sound infrastructure & professional outlook. Major hospitals in Chennai, Mumbai, Hyderabad & New Delhi have recorded a 125 patient flow from the neighboring & South-East Asian countries. This is because people have realized that they can now have access to international quality medi-care at 10% of international costs in India. ..12..

Technologies of the new millennium including ECG through conferencing will soon be introduced in India, making it feasible for doctors to benefit from the advice of other experts. Indian doctors performed the country’s first robotic heart surgery which reduces the risk and trauma associated with critical conditions.

Apart from that India has also become an important destination for medical conferences. Major international medical conferences on ophthalmology, oral cancer, etc. were held in India with many more on the anvil.

International Conference An international health and medical tourism conference is slated to be held towards the end of this year at Bangalore, which will see delegates from various South- East Asian countries, the Middle-East and even Africa participating. This will serve as an ideal platform for Incredible India to market its health and medical tourism products and services.

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INDIAN HEALTHCARE SPECIALTIES
Cardiac Care
Cardiac care has become a speciality in India with names such as the Escorts Heart Institute, AMIIS and Apollo hospitals becoming names to reckon with. They combine the latest innovations in medical electronics with unmatched expertise in leading Cardio logistics and cardio-thoracic surgeons. These centers have the distinction of providing comprehensive cardiac care spanning from basic facilities in preventive cardiology to the more sophisticated curative technology. The technology is contemporary and world class and the volumes handled match global benchmarks. They also specialize in offering surgery to high risk patients with the introduction of innovative techniques of minimally invasive and robotic surgeries.

The success rates here at these hospitals in India are at an average of 98.5% which are at par with the leading cardiac centers around the world.

They are in possession of cardiac care units with sophisticated equipments and investigate facilities like echocardiography with colored Doppler, Nuclear scanning and Coronary Angiography.

Dialysis and kidney transplant
Common diseases like Diabetes, Hypertension and Chronic Glomerulo-Nephritis can lead to permanent loss of renal function with Dialysis and renal transplantation being the frequent outcome. The emergence of new therapeutic interventions has created opportunities in India to manage the progression of renal diseases. For those who need replacement therapy, services like Hemodialysis, Chronic Ambulatory peritoneal dialysis (CAPD), and transplantation are also available. Patients can also avail of the Bicarbonate Dialysis facilities. The cost of getting a dialysis is around Rs.1700-1800 per dialysis. Similarly a Kidney transplant package in India is available for around Rs.3 lakh.

Neurosurgery & Trauma surgery
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Other routine procedures performed with excellent results are replacement Arthroplasties, Diagnostics and Operative Arthroscopy, spinal surgery including Harrington rod instrumentation, corrective and reconstructive procedure for poliomyelitis and cerebral palsy.

In addition the advanced Luque technique is employed for the correction of complex scoliosis and decompression and stabilization of fractures of dorsal and lumbar spine by neurosurgeon with excellent training and background.

Some super speciality hospitals in India like AIIMS, Ram Manohar Lohia hospital, Bombay hospital, Jaslok hospital and Apollo hospitals have advanced facilities dedicated to the treatment of entire range of brain and spinal disorders with highly experienced neurosurgeons, neurologists and neuro-anaesthetists.

Joint replacement surgery
Shoulder/ hip replacement and bilateral knee replacement surgery using the most advanced keyhole or endoscopic surgery and anthroscopy is done at several hospitals in India including the Apollo hospital, Delhi; Bombay hospital, Mumbai and Madras Institute of Orthopedics and Trauma Sciences. Some hospitals like Apollo in Delhi have operation theatres with laminar air flow system. A knee joint replacement costs about Rs.2 and a half lakhs in India.

Refractive surgery
This type of surgery is gaining popularity in India both among the public as well as the opthalmogistis. Till a few years ago only a few centers performed high volume radial keratotomy. Today, the highest international quality of eye care for cornea, cataract, squin and glaucoma is available in over 40 centers all over India. When it comes to reliability India has the best ophthalmic surgeons with clinic-academic expertise honed to perfection in the best possible institutions. The no stitch cataract surgery with the most modern way of removing cataracts through the use of phacoemulsification procedure can be performed in India for as little as Rs.20000 for both the eyes. Facilities for PRK, Myopia and astigmatism are now available in almost all parts of the country. Hyperopic and LASIK are available

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and even supra-hard cataracts are treated using just 1mm instead of 3mm incision size.

Nuclear medicine
This is now common place, as it involves use of radioactive isotopes in very small doses in diagnosing and treatment of diseases, radioactive medicine is injected or administered orally and the distribution in the organ is scanned using a gamma camera.

Various non cardiac planar/SPECT studies for bone, thyroid, liver and lung scanning functions are performed at specialized centers in India.

Cosmetic surgery
A new dimension of the medical field taking off in India is the cosmetic surgery which utilizes some of the latest techniques in corrective procedures. Some disfigurations corrected include hair restoration, rhinoplasties, stalling of aging process, dermabrasions, otoplasty for protruding ears, chin and cheek enlargement, lip reductions, various types of breast surgeries and reconstructions and liposuction.

Non invasive surgical procedures like streotactic radio surgery and radiotherapy for brain tumors are practiced successfully.

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ANCIENT INDIAN THERAPY
AYURVEDA
Of the many forms of alternative medicine currently in vogue in India, yoga and ayurveda almost certainly lead the pack- and both forms have much in common. Both, for instance, date back to over 5,000 years ago, and have a long history of carefully-researched and highly scientific reasoning to back them up. Both seek to integrate mind, body and soul for holistic healing, and both are increasingly gaining popularity as therapeutic sciences that aim to heal without causing harmful side effects. Ayurveda' is derived from the two words `ayu' (`age' or `life') and `veda' (a knowledge of').

As is apparent from the word itself, ayurveda centers round a close understanding of life; and in the case of ayurveda, this means an intricate relationship between the many aspects of human life, physical as well as mental and spiritual.

According to the tenets of ayurveda, the human body comprises of five basic elements- earth, fire, water, air and ether (space). Each of these elements is also present in the atmosphere surrounding humans, and their combination affects the human body and mind. These combinations include vatadosha (ether + air, which affects the nervous system, circulation, elimination and respiration); pittadosha (fire + water, which governs digestion and metabolism) and kaphadosha (water + earth, responsible for growth as well as for immunity).

Ayurveda bases itself on these three doshas, using the premise that each individual is a unique combination of the doshas, and any imbalance in this combination is the ultimate cause of all diseases. The cure for these diseases, then, lies in a customized cleansing process, tailor-made specifically for the affected individual. The cure is known as `panchkarma' and it aims to treat the disease by eliminating accumulated toxins from the body. Panchkarma can take many different forms, ranging from special diets and oil massages to therapeutic vomiting and purgation.

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Ayurvedic treatments, if rendered properly, can be very helpful in curing a range of illnesses and physical disorders, including asthma, diabetes, obesity, skin diseases, digestive disorders, joint disorders, allergies and more. Treating diseases of a complex type will obviously take much more than a mere weekend of ayurvedic massages, but a quiet 3 days (or even a week, if you can afford to spare the time) is good enough to get a very rejuvenating taste of what ayurveda is all about.

A huge number of ayurvedic resorts and spas are mushrooming all across India, and all of them offer a tempting range of packages to choose from. Some are specifically geared towards curing certain minor ailments, although most offer a short-term but highly intensive `ayurveda package' which runs the gamut from oil massages and herbal steam baths to special diets and the pouring of medicinal oils on the forehead of the individual.

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Among the many places that offer excellent ayurvedic packages are: Ananda in the Himalayas Tehri Garhwal (Uttaranchal)

Sereno Spa South Goa

Aayurgram Ayurvedic Health Resort Bangalore

Ayurveda & Yoga Retreat Coonoor (Tamilnadu)

Kadavu Ayurvedic Health Centre Malappuram (Kerala)

Travancore Heritage Ayurvedic Centre Chowara (Kerala)

Kairali Ayurvedic Health Resort Palakkad (Kerala)

Angsana Oasis Spa and Resort Bangalore

Keraleeyam Ayurvedic Health ResortAlappuzha (Kerala)

Manaltheeram Ayurveda Beach VillageChowara (Kerala)

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HYDROTHERAPY
Hydrotherapy, or water therapy as it is also known centres around (as you've probably guessed) the use of water as a healing agent. The buoyancy, viscosity and mineral components of water are used through hydrotherapy to heal or relieve ills as varied as fatigue, sore throats, and colds, inflammation of the joints, jaundice, rheumatism, arthritis, spondylitis, insomnia, soft tissue injuries and even diabetes.

As an alternative system of healing, hydrotherapy is one of the oldest, safest and cheapest- which is definitely part of the reason why it's swiftly gaining in popularity. Hydrotherapy is no upstart; it's been around for more than 5,000 years, when the first mineral and thermal baths appeared in Greece. The Greeks, however, were not the only people to realize the healing powers of water. They were followed in their appreciation of the therapeutic liquid by the Romans (who are credited with having set up well-planned baths all across their empire); the Egyptians, the Japanese and the native Indian Americans. Most modern techniques borrow from both Eastern and Western forms of water therapy, and span a vast range of treatments. Basically, hydrotherapy is instrumental in stimulating blood circulation, increasing the production of stress hormones, improving the immune system and lessening pain sensitivity. The most common curative methods used in hydrotherapy include:

Cold Baths: Cold baths are used mainly as a means of stimulating blood circulation, and are also used for reducing swelling.

Steam Baths: Hot steam helps encourage sweating, which in turn opens the skin's pores, leaving the individual feeling refreshed and rejuvenated. It's not specifically healing, but it works wonders if you're feeling tired and drained, and can be an effective means of detoxification.

Neutral Baths: A neutral bath-as the name suggests- uses water that is neither hotter nor colder than the temperature of the human body (cold or hot water draws or

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transmits heat to or from the body, as the case may be). For a neutral bath, the individual is immersed in water that is maintained at a steady temperature of between 33.5°C and 35.6, for about half an hour. This has a sedative, and even soporific, effect on the patient and is used to calm the nervous system.

Floatation: As relaxing and refreshing as a neutral bath, floatation involves lying face up in a dark, enclosed tank of warm, heavily salted water.

Hot and Cold Sprays: High-pressure spray jets of hot or cold water are used to heal or relieve a number of minor ailments, and mainly to stimulate organ function, the nervous system and the immune system.

Hot and Cold Compresses: Both hot as well as cold compresses actually start off as cold compresses- a cloth dipped in ice-cold water and left on the effected part of the body for a certain period of time. In the case of a cold compress, the pack is replaced by an equally cold pack once it begins to lose its chill. In the case of a hot compress, the pack is left on and allowed to heat up by the warmth of the body. Both types of compresses are used in various ways, especially to treat acute injuries.

Ice Packs: Ice packs- which contain crushed ice or a special gel- are applied to the body to reduce swelling, pain and inflammation.

Wet Sheet Packs: A wet sheet pack (also known as bodies wrap) is, as the name suggests, a procedure in which the entire body is wrapped in a cold, wet sheet that is in turn covered with a woolen blanket. The sheet is left in place until it dries by the warmth of the body (usually about half an hour to relieve a fever; longer to relax and soothe the body; or up to 3 hours to induce sweating, which can be a good detoxification method for those with drinking or smoking problems).

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Among the spas in India that offer hydrotherapy treatments are:

Ananda in the Himalayas Tehri Garhwal (Uttaranchal)

Spa Aguada Goa

Angsana Oasis Spa and Resort Bangalore

The Leela Palace Bangalore

Golden Palms Spa and Resort Bangalore

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YOGA
Yoga, now recognized globally as a highly effective form of alternative medicine, originated in India about 5,000 years ago as a discipline that sought to unite the moral, mental and physical aspects of human life to contribute to the overall wellness of the individual.

Yoga is believed to have been propounded by the sage Patanjali (2nd century BC). Patanjali, in his treatise (known as the sutras) of yoga, explained the basics of yoga, its benefits and its steps (padas), without going into the details of what postures to adopt, how to breathe and so on.

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HEALTH CHECK-UP
Many common and life threatening conditions can be treated successfully if detected early. Many leading hospitals in India have health check-up programs that screen every part of the body meticulously and professionally. A proper health check-up scans your bio-history, interprets signal and provides the opportunity for the proverbial ‘stitch in time’. A heart check-up constituting of echocardiography, consultation by a senior cardiologists, blood tests, general test & haemogram can go long way in ensuring a healthy heart. The test can be done at any of the leading cardiac hospitals or private clinics. A comprehensive health check-up contains the following tests: • • • • • • • • • • • • • • • • • Doctor’s consultation and full medical examination Blood tests Blood group Blood sugar Blood urea Serum uric acid Serum creatinine Serum cholesterol Lipid profile Urine and faeces examination X-ray chest PA ECG Exercise stress test (tmt) Stress screening by psychologist Gynecologist consultation and PAP smear test Post check-up consultation Optional tests

Some additional tests may be advised by your doctor like: • • Pulmonary function test Ultra sound screening for the abdomen ..24..

• • • • • •

ENT examination Screening for liver disease Screening for thyroid disease Hepatitis B screening Test for AIDS Screening for Kidney disease

These tests can be done in leading private and public hospitals. The full health checkup package costs between Rs.2000-2500.

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PROMOTION OF MEDICAL TOURISM
The key “selling points” of the medical tourism industry are its “cost effectiveness” and its combination with the attractions of tourism. The latter also uses the ploy of selling the “exotica” of the countries involved as well as the packaging of health care with traditional therapies and treatment methods.

Price advantage is, of course, 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.

The price advantage is however offset today for patients from the developed countries by concerns regarding standards, insurance coverage and other infrastructure. This is where the tourism and medical industries are trying to pool resources, and also putting pressure on the government. We shall turn to their implications later.

In India the strong tradition of traditional systems of health care in Kerala, for example, is utilized. Kerala Ayurveda centres have been established at multiple locations in various metro cities, thus highlighting the advantages of Ayurveda in health management. The health tourism focus has seen Kerala participate in various trade shows and expos wherein the advantages of this traditional form of medicine are showcased.

A generic problem with medical tourism is that it reinforces the medicalised view of health care. By promoting the notion that medical services can be bought off the shelf from the lowest priced provider anywhere in the globe, it also takes away the pressure from the government to provide comprehensive health care to all its citizens. It is a deepening of the whole notion of health care that is being pushed today which emphasizes on technology and private enterprise.

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The important question here is for whom is ‘cost effective’ services to be provided. Clearly the services are “cost effective” for those who can pay and in addition come from countries where medical care costs are exorbitant - because of the failure of the government to provide affordable medical care. It thus attracts only a small fraction that can pay for medical care and leaves out large sections that are denied medical care but cannot afford to pay. The demand for cost effective specialized care is coming from the developed countries where there has been a decline in public spending and rise in life expectancy and non-communicable diseases that requires specialist services.

MEDICAL TOURISM: COST COMPARISONS
Type Partial replacement Full replacement Orthopedic surgery Cardiac surgery $4,000- $9,000 or $30,000 £6,000 Knee surgery £8,000 $50,000 N.A £30,000 care) £20,000 care) (private (private $4,500 $18,000 N.A hip $3,000 $39,000 N.A India hip $4,500 U.S. $18,000 U.K. N.A.

Gall surgery

bladder $7,500

$60,000

N.A

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Dental care
Type Tooth extraction Two dental bridges Filling Root canal $20 - $40 $200 - $400 $300 - $400 $3,500 N.A N.A N.A N.A India N.A. N.A U.S. $350 $5,200 Thailand $30 N.A Hungary N.A $990

N.A: Not available

(Figures are estimated, are in U.S. dollars or U.K. pounds, figures vary due to prices charged by different medical centres and patient profile and do not include travel and accommodation costs)

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KERALA - THE PIONEER STATE
Kerala, or God’s Own Country as its corporate slogan goes, has pioneered health and medical tourism in India. They have made a concerted effort to promote health tourism in a big way, which has resulted in a substantial increase of visitor arrivals into the state. Kerala and Ayurveda have virtually become synonymous with each other. However, though Kerala has strongly focused on Ayurveda and its wide array of treatments and medications, good facilities are also available in the other traditional forms of medicine as well as in modern medical treatment.

The bias towards health tourism in Kerala is so strong that Kerala Ayurveda Centres have been established at multiple locations in various metro cities, thus highlighting the advantages of Ayurveda in health management. The health tourism focus has seen Kerala participate in various trade shows and expos wherein the advantages of this traditional form of medicine are showcased.

Medical Tourism in Kerala
• • • Kerala is already marketed as a health destination mainly for its Ayurveda packages Medical tourism is marketed along with ayurveda and to her health packages. Major hospitals like KIMS, Trivandrum, Lake Shore and AIMS in Kochi, and MIMS, Calicut have pioneered joining hands with the Government promoting Medical Tourism. • • Globalization and economic liberalization have given a boost to the specialized Medical Service Sector Health Insurance Companies are playing a major role in Medical Tourism.

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Kerala pioneered health and medical tourism in India through Ayurveda

Medical Tourism Product
• Medical tourism is like any leisure product where service components like airlines, hotels, travel companies, transportation, food outlets are offered and medical treatment at the best hospitals • The medical treatments for various ailments are packaged with recuperative leisure packages at world class tourist resorts.

Kerala a Medical Tourism Destination
• • • • • • • Well connected by Air from major medical tourism markets in the Middle East European markets and South Asia Moderate weather throughout the year Advanced and sophisticated hospitals of International standards located in Kerala. Renowned doctors specialized in almost all major disciplines. Trained paramedical staff and technicians available in Kerala Easier communication with majority English speaking public The higher hygienic standards of Kerala ..30..

• • • • • •

The developed tourism industry in Kerala with its array of high quality resorts and hotels. Ideal setting for an excellent recuperative holiday Medical tourism packages offered and marketed by tour operators joining hands with excellent hospitals Incredibly competitive cost for packages of medical treatment and surgery compared to other countries Honoring of medical insurance by hospitals in Kerala Marketed efficiently in source markets

Distribution - Medical Tourism packages
• • • • Distributed widely and brought to the doorstep of the customers by the tourism industry. Made available through major tour operators. They sell it as other holiday packages. Made it easy for the patients. The Department of Tourism, Kerala pioneered in promoting Kerala as a medical tourism destination in the International market. The Great India Tour Company (GITC) launched special medical tourism packages under brand name “Heavenly Healing” in the international tourism marts in association with Kerala Institute of Medical Sciences (KIMS).

The package …
• • • • • • • • Medical history emailed and discussed Patient received at the airport, an escort takes over. Transferred to a hotel or resort. Escort takes the patient to the hospital as per appointment with doctor and admits into the hospital. Surgery or treatment conducted. Discharge and recuperative holiday at a resort. Post treatment check up, transfer to airport and departure. Billed as a package all inclusive for the patient and accompanying person.

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Demand for treatment in Kerala
• • • • There is an existing demand for treatment, from countries like Maldives, Bangladesh, Gulf countries and some European countries. European Countries are finding it difficult to offer surgeries in time, due to heavy wait-list. The Non-Resident Keralites are good spokespersons in the originating countries and prefer their home country for treatment. International Corporate houses offer medical treatment facilities to the employees and family / are focusing cost effective options.

Some Health indicators of Kerala A well quoted & most discussed phenomenon
• • • • • • • • • • • • Population density - 819 per sq km Annual Per capita income – Rs 17,756 (national avg - Rs 14,712) Sex ratio - 1036 females to 1000 males Population growth rate – 9.4 % Low infant and child mortality - Infant Mortality Rate – <12 High life expectancy at birth - Life expectancy –75yrs Virtual elimination of many communicable diseases Replacement level birth rate in many districts Birth rate – 18.2 per 1000 Death rate –6.2 per 1000 Maternal mortality rate - <2 per 1000 Per capita expenditure on health care by Kerala population - 11.95 compared to the all India figure of 6 %.

Health-care Infrastructure
• • • • Bed availability - 377 per 1000 population Kerala spends > 9% of the State GDP on health Kerala Health Sector – Private sector dominates with 70% share on health care Health Insurance < 9 % covered

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Synergy between Hospitals and an active Tourism Industry
• • • Growing tourism industry in Kerala enhances the quality professional services in this sector. Availability of excellent hotels, resorts at beaches, backwaters, hills, plantations… managed professionally Patients feel happy having experienced a dream destination like Kerala.

Kerala poised for a leap in Medical Tourism
• • • • • • Hospitals are joining hands with tourism industry for services. Government has taken it up as a new thrust-area in Tourism, marketing the concept. Private sector is enthusiastic in selling the services. Trained youth entering the industry in big numbers Better sharing and dissemination of information on health management through internet and satellite channels. State is technology savvy, utilizing video conferencing with experts and other modern communication facilities.

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KARNATAKA’S FORAY INTO THE HEALTHCARE SECTOR
The department of tourism, government of Karnataka, has ambitious plans for the state. According to D B Inamdar, minister for tourism, "The idea is to make Karnataka a top health tourism destination, not only in India but internationally. We want to lure foreigners to Karnataka to avail of our sophisticated facilities and subsequently induce them to enjoy our multiple tourism offerings. This endeavour will have a positive impact on the entire economy of the state." In fact, the government is setting up a Bangalore International Health City Corporation which will cater to patients for a wide variety of health care products and treatments.

The recent operations of children from Pakistan, who have sought medical treatment in Bangalore, have not only helped to boost the state economy but more importantly, helped in fostering goodwill, peace and harmony between India and Pakistan. Without doubt, Indian doctors are among the best in the world and given the right atmosphere and environment, they can enhance the image of Incredible India as a health and tourism destination.

The state also boasts of having the unique property, Golden Palms Spa & Resort, which is the one and only resort in the country where a guest can have a complete range of pathological tests, dental treatment, electro-cardiograms, stress tests, X-rays, and even sonography tests. To crown it all, there is even a mini-operation theatre for cosmetic surgery performed by world renowned surgeons in the field.

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MEDICAL TOURISM AND PUBLIC HEALTH SERVICES
Medical tourism is going to only deal with large specialist hospitals run by corporate entities. It is a myth that the revenues earned by these corporates will partly revert back to finance the public sector. There is ample evidence to show that these hospitals have not honoured the conditionalities for receiving government subsidies – in terms of treatment of a certain proportion of in patients and out patients free of cost. If anything, increased demand on private hospitals due to medical tourism may result in their expansion. If they expand then they will need more professionals, which means that they will try to woo doctors from the public sector. Even today the top specialists in corporate hospitals are senior doctors drawn the public sector. Medical tourism is likely to further devalue and divert personnel from the public sector rather than strengthen them. Urban concentration of health care providers is a well-known fact – 59 per cent of India’s practitioners (73 per cent allopathic) are located in cities, and especially metropolitan ones. Medical tourism promotes an “internal brain drain” with more health professionals being drawn to large urban centres, and within them, to large corporate run specialty institutions. Medical tourism is going to result in a number of demands and changes in the areas of financing and regulations. There will be a greater push for encouraging private insurance tied to systems of accreditation of private hospitals. There is a huge concern in the developed countries about the quality of care and clinical expertise in developing countries and this will push for both insurance and regulatory regimes. The potential for earning revenues through medical tourism will become an important argument for private hospitals demanding more subsidies from the government in the long run. In countries like India, the corporate private sector has already received considerable subsidies in the form of land, reduced import duties for medical equipment etc. Medical tourism will only further legitimize their demands and put pressure on the government to subsidies them even more. This is worrying because the scarce resources available for health will go into subsidizing the corporate sector. It thus has serious consequences for equity and cost of services and raises a very fundamental question: why should developing countries be subsidizing the health care of developed countries?

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DIFFERENT VIEWS ON - SHOULD PUBLIC HOSPITALS PARTICIPATE IN MEDICAL TOURISM?
No, why promote private business interests with government’s money?’ -Ravi Duggal
The setting up of the Medical Tourism Council of Maharashtra (MTCM) collaboratively by the state government and Federation of Indian Chambers of Commerce and Industry’s (FICCI) western regional centre is a contradiction of sorts. Tourism is associated with pleasure, fun and relaxation and I fail to understand how medical care can become a tourist attraction. Those seeking medical care are ill, under tremendous stress, and are in a vulnerable position. Hence promoting medical care through a tourism council in itself is a sick concept!

If FICCI wants to promote private health care business worldwide it has a right to do so. But why involve the state government in promoting private health care business. All these years the central and state governments have given loads of subsidies to the private health sector, whether it was land to construct hospitals or medical education to produce doctors for the private sector, or subsidised bulk drugs to private formulation units, or tax and duty waivers to import expensive medical equipment etc.

But the private health sector, which is being promoted through this council (mainly the five star hospitals), and which has benefited most from these subsidies, has been socially irresponsible. What is worse is that almost all these hospitals are registered as trust hospitals, which means that for their not-for-profit status they have obligations under the Public Trust Act to provide health care free to the extent of 20 per cent of their resources.

Where is the accountability of this provision? The charity commissioner is turning a blind eye and the hospitals are having a joy ride, and it is well known that the free patients on their list are relatives of hospital staff, bureaucrats and ministers. The state becoming party to such a venture is a grossly unethical act. Given the declining public health situation of the state, the latter seeking to promote medical care for the rich and ..36..

wealthy, instead of focusing its energies and resources on strengthening the public health system for the benefit of the poor is just not acceptable. The state is violating the principle of non-discrimination of the International Covenant on Economic, Social and Cultural Rights. The government’s own studies and reports reveal the pathetic state of the public health care system in both rural and urban areas and yet the government chooses to rub shoulders with FICCI to promote private business interests in the health sector.

The setting up of this council is driven by two business factors. First the idle capacity of these large elite hospitals and second the long waiting lists for selective surgeries and medical procedures in the developed world. .

So I would like to urge the Maharashtra government to stay out of this and take to task these very hospitals enlisted on the MTMC website to honour their commitments as trust hospitals using their idle capacity for treating the poor free of cost as mandated by the Trust Act, and provide free diagnostic services using equipment which was imported with duty concessions. So instead of seeking export revenues, the state should be looking at generating revenues by demanding accountability from these hospitals. These should form the “benchmarks” and “best practices” which Sushil Kumar Shinde referred to in his statement during the inauguration of the Council and should be of concern to the state government.

‘Yes, it can revolutionise public health care scenario’
Public hospitals present a very strong case in being a part of the Maharashtra Medical Tourism Council. These hospitals have professionals who have, perhaps, the maximum exposure to diseases and ailments; a record number of procedures are performed by them and are recognized worldwide for their competence. Once this competency is leveraged, by seed investments in technology and ambience oriented infrastructure, they can be attractive for the foreign tourists. Then arises the question- whether they should participate in the Council?

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According to me, why not? The critics fail to see the in-built advantages for the Indian society if public hospitals participate in this exercise actively. A parallel revenue stream, apart from the taxpayer’s money, can bring about a revolution in the Indian public health care scenario. Today, the public health sector and related institutions are suffering because of budgetary constraints. Look at the possibility of the public hospitals being technologically upgraded to world class standards with this possible source of income. Also, with exposure to the paid medical service market, the spirit of competition will germinate in the public hospitals, which will enhance their efficiency, service delivery levels and subsequently their image. Medical tourism is not about primary and secondary health care in our villages and towns; it is also not about critical care and emergencies. So the argument that millions would be deprived of public facilities does not hold water. Hence all these segments will remain unaffected by the surge of medical tourists in public hospitals. In the present form, medical tourism concept in India is based on leveraging the cost differentials of medical treatment by the foreign nationals, or Indian system of medicine, or recuperation and rehabilitation. This is only possible in planned treatments and procedures and to some extent, preventive care and diagnostics. Thus, with the kind of resource inflow envisaged because of tourism, things can only improve in public hospitals.

Therefore, an approach to attract medical tourists, in medium and long run, will be beneficial to Indian society at large.

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MEDICAL TOURISM IN METROS& SUBURBAN CITY
DELHI:
Although Delhi has witnessed an unprecedented growth in health care industry, how far has the capital become successful in attracting the medical tourist to its swanky and big hospitals? Sapna Dogra finds out

When baby Noor Fatima, a two-and-a-half- year old Pakistani girl, successfully underwent an open heart surgery in India, she opened news vistas reminding the potential of medical toursim.The Ministry of External Affairs took this opportunity to encourage medical diplomacy, by facilitating the visit of cabinet ministers and provincial leaders to India for treatment.

Medical tourism is the buzzword now. The government as well as private players are keenly assessing the potential and means to tap the same. The boom in state-of-the-art hospitals and well-qualified doctors, have attracted the patient population from neighbouring countries, the Middle East and the West.

The equation is ‘First World treatment’ at “Third World prices”. A CII-McKinsey report last year, postulating the opportunities in health tourism, states that the medical tourism market in the country pegged a 30 per cent growth in 2000 and it has been growing at the rate of 15 per cent for the past five years.

“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,” adds the report. One of the Indian states, Kerala, setting an example by attracting health tourists, has emerged successful in generating revenues from medical tourism. Hospital groups in Delhi have realized the potential of health/ medical tourism but most of them are playing it by the ear.

Among private players, Apollo has been a forerunner in health tourism. It has been a choicest destination for patients from Southeast Asia, Africa, and the Middle East. The group has tied up with hospitals in Mauritius, Tanzania, Bangladesh and Yemen

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besides running a hospital in Sri Lanka, and managing a hospital in Dubai. In 2002, the number of patients who visited the hospital was 3001 and about 700 were hospitalized. Along with providing treatment, the stay of the foreign patients is taken care of by the hospital itself. The group has tied up with hotels in Delhi for this purpose. According to Dr Chabra, additional medical director, ISIC (Indian Spinal Injury Centre), ISIC is another destination for patients from neighbouring countries, Gulf and a few NRIs from the US.

Now, to attract more people, the emphasis is on vacation plus treatment and special packages have been planned for this. On the anvil is another plan to make the patients and their relatives stay in the hospital complex with all the luxuries a hotel provides. Dr Shakti Gupta, AIIMS, stresses on the need to export health services. According to him, Indian doctors, medical services, and hospitals are at par with good hospitals in Europe and the US, so it is the right time to make the most of it. AIIMS is a destination for patients from Nepal, Bangladesh, Bhutan, Myanmar, Mauritius, Malaya and Pakistan. Besides regular patients from the Middle-East, an occasional patient from the US drops in. Patients from Pakistan, especially children with heart afflictions, have been regularly coming to AIIMS’ heart centre.

According to Dr Gupta, AIIMS was made for the entire south-east Asia populace and since it is a government institute there are no plans to attract more foreigners. The attractions at AIIMS include cardiac surgery, neurosurgery, cancer treatment and ophthalmic procedures. “The services are charged on actuals and ours being a government institute we are not angling to make money but are here to serve the people,” stressed Dr Gupta.

The Metro hospitals and Heart Institute, Noida, also manages to attract patients from Nepal, Bhutan, Sri Lanka, Bangladesh and a few from Maldives and the Gulf region. Their motto is to extend excellent health services to people who travel here for health care and also for tourists who need health care while their stay in India. Indian hospitals getting recognition from international insurance companies will bring in more patients from abroad, says Anil K Maini, head, marketing, health care business, Escorts Heart Institute and Research Centre. ..40..

The centre is emerging fast as a favourite destination for patients from neighboring countries, Africa and CIS. With BUPA recognition, patients from the UK are coming here for treatment. About 1,000 patients from abroad are treated in Escorts on an annual basis. Although only a few hospitals are making conscious efforts to increase the existing inflow of health tourists, nobody denies the huge potential medical tourism has. And it will not be long before its full potential is realised, provided we cultivate the service mind set, put in place an accreditation system and project our capabilities overseas through multiple media.

LIST OF HOSPITALS IN DELHI Name Jeevan Anmol hospital G.M.Modi hospital Indraprastha hospital Tirath Ram Shah hospital Sitaram Bhartia Institute Batra hospital Pushpanjali Centre Rajiv Institute Centre M.G.S hospital (Delhi) Rockland hospital Sonia hospital (Delhi) Veeranwali International hospital 35/37 Rohtak Road, Punjabi Baug Tara Cresent Road Nangloi National Highway No.10 Chandragupta Marg, Chanakyapuri 100 130 65 70 Gandhi & Sawhnex Marg, Rajpur Road B-16, Mehrauli Industrial Area 1,Tuglauabad Institutional Area 183 64 310 Address Mayur Vihar Phase-I Mandir Marg, Saket Apollo Sarita Vihar, Mathura Road Bed Capacity 125 100 600

Medical A-14/15, Pushpanjali Vikas Marg 60 Extn Cancer D-18, Sector V, Rohini Research 160

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MUMBAI:
STRENGTH Expertise and skill The city boasts of doctors and nursing staff whose expertise is comparable with international standards. And, as Dr. Nilima Kshirsagar, dean of KEM Hospital, puts its, “Real medicine is provided speedily and efficiently”.

Extensive infrastructure Mumbai has one of the largest healthcare facilities run by the Municipal Corporation, state government, charitable trusts and private owners. Official estimates say the city has 33000 beds, four tertiary care hospitals, several peripheral hospitals. Several specialty and super specialty hospitals are spread across town, from Mulund in the north to south Mumbai. State-of-the-art equipment is available at most private hospitals as well as a handful of public hospitals. Several tourist destinations nearby Maharashtra is dotted with tourist destinations. Packages can be developed to lure patients. As state Health Minister Digvijay Khanvilkar had in an earlier interview said: “Even in these places, our rural and primary healthcare facilities are in place”. Last word “For it to work, we have to develop products not only related to healthcare but also tourism. But they should have a USP and be cost advantageous. There is nothing wrong with such a plan for all economies work on cross – subsidy and it can be the same here too. Interaction with foreign patients will also improve quality of treatment, “says Brigadier Joe Curian, CEO of S L Raheja Hospital. Comparative cost A knee replacement that costs $6000(Rs.2.73 lakh) in India would cost $10000(Rs.4.55 lakh) in the UK. A cardiac bypass costing $15000(Rs.6.82 lakh) in the UK would cost up to Rs.3 lakh here.

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WEAKNESS Benefits only private hospitals The main beneficiaries would be private and charitable hospitals. Given the conditions that public hospitals work under, it’s unlikely that foreigners would consider them. “Most charitable hospitals have over half their beds vacant. And the charity commissioner is doing nothing about it, “says Ravi Duggal of centre for Enquiry into health and Allied Themes (CEHAT)

Lack of funds Even though the government aims to bring public hospitals under the purview of health tourism, there is an urgent need for facilities, “If we want to lure people from abroad, we have to create facilities similar to that of nursing homes,” says Kshirsagar. “The only void is the marketing of public hospitals,” says Sushil Jiwarajka, chairman (western zone), FICCI.

Costlier than other cities Where Mumbai is likely to lose out is cost of treatment. A bypass in Mumbai is nearly comparable with cities like Delhi and Chennai costing up to Rs.3 lakh in public hospitals. In Kolkata it costs between Rs.1.12 lakh and Rs.1.33 lakh at a leading hospital. A caesarean costs over Rs.50000 in a few hospitals, while in Bangalore it costs Rs.23900.

Last word “In a city where people are dying of dengue and falciparum malaria, it shows how disassociated the government is about ground realities. It is nothing but a political ploy,” says Dr. Arun Bal, of Association for consumer Action for safety and health (ACASH).

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LIST OF HOSPITALS IN MUMBAI Hospital Address Bed Capacity

Asian Heart Institute Bhagwati Hospital Bhaktivedanta Hospital Bhatia Hospital Bombay Hospital Breach Candy Hospital and Research Center Cooper Hospital Guru Nanak Hospital Hinduja Hospital J.J Hospital Jaslok Hospital K.E.M Hospital Lilavati Hospital Nair Hospital Nanavati Hospital Tata Memorial Hospital Wockhard Hospital Limited

Bandra (East) Borivali (West) Mira Road Grant Road Marine Lines Breach Candy

N.A N.A N.A N.A N.A 175

Vile Parle Bandra (East) Mahim Byculla Peddar Road Parel Bandra Recl. Mumbai Central Vile Parle Parel Mulund

N.A 150 350 N.A 377 N.A 300 N.A 400 N.A 222

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PUNE:
It was economical for Robert Dunn to fly from London to Pune for a knee replacement surgery. What would have cost him Rs 15 lakh in Britain was done at a minimal cost of Rs 1.95 lakh in Pune.

What’s more, Sancheti Hospital’s ‘Medical Tourism Department’ took care of all his demands and ensured that his 17-day stay was an unforgettable experience.

‘‘People seeking health solutions for their ailments from various countries have travelled to India and Pune over the last few years. But the inflow of patients has increased not only from countries like the Middle East and Africa but Europe as well,’’ says Manish Sanghvi, Director, Administration at Sancheti Hospital and in charge of the newly set up Medical Tourism Department that will cater exclusively to international patients. The hospital has an average of 7-8 patients per month from overseas, says Sanghvi, adding that in the last four years at least 250 international patients have been treated. The patients mainly seek treatment for joint- related problems at the orthopaedic specialty hospital. According to Sanghvi, the hospital has even prepared a medical tourism package that organises sightseeing tours to tourist spots in the city and elsewhere. Sanghvi even recalls that one family flew down from Kenya for the knee replacement surgery of their father. ‘‘They wanted to go to Agra to see the Taj Mahal while the kids wanted to hang out at the pubs. While their father was recuperating, family members decided to make the most of their stay in Pune,’’says Sanghvi. The hospital’s medical tourism department arranged everything and their month’s stay cost them just Rs 6-7 lakh.

He pointed out that the hospital was leaving no stone unturned to woo medical tourists. “Recent reports have revealed that by 2012, medical tourism in India would be a Rs 10,000 crore opportunity. Our treatment is not just about new technologies and good doctors. It is also about family values and genuine concern for our patients,” insists Sanghvi. While international patients are always suspicious regarding the treatment.

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LIST OF HOSPITALS IN PUNE Hospital Address Bed Capacity

Grant Medical Foundation Lokmanya Hospital Sanjeevan hospital Sancheti hospital Sane Guruji Arogya Kendra Deenanath Mangeshkar hospital Kotbagi hospital Niramaya hospital Jehangir Research hospital &

Sassoon Road

535

Chinchwad Karve Road Shivajinagar Hadapser Erandwane Aundh Mumbai Pune Road Medical Sassoon Road

50 125 110 200 450 50 100 266

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MAHARASHTRA’S UNLIMITED POTENTIAL
This state, as a gateway to India, offers tremendous potential to develop medical tourism. The latest addition in Mumbai is the Asian Heart Institute at Bandra-Kurla Complex, which offers state-of-the art facilities for all types of heart complications and even offers preventive cardiological treatment to avoid heart ailments and also to keep under control a host of heart problems. This institute which is in collaboration with the Cleveland Institute, USA, offers ‘five-star’ services at reasonable prices. There are even provisions for financial assistance which is offered through various trusts associated with the institute.

There are a wide range of hospitals which help to promote medical tourism in the state. Some of these are Lilavati Hospital, Jaslok Hospital, Bombay Hospital, Hinduja Hospital, Wockhardt Hospital and Apollo NUSI Wellness Retreat. Hotels like Hyatt Regency, JW Marriott, Renaissance and Resort, also offer extensive spa facilities aimed at rejuvenating both the domestic and international tourist.

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PUBLIC SURVEY & ANALYSIS
A survey was conducted by me to study the awareness amongst the general the general public about Medical Tourism and their general behaviour. For this purpose I selected 50 individuals randomly of an age, sex and occupation. The results obtained and their conclusions were as follows:

1. Have you heard about the term ‘Medial Tourism’? Yes-88% No-12%

Majority of the people have heard about the term Medical Tourism which means that there is awareness amongst the general public about this field.

2. Has any one of your near one been to a foreign country for treatment purposes? Yes-48% No-52%

3. Do you know about celebrities traveling to the US for medical treatments? Yes-92% No-8%

The above questions (1 & 2) were asked to check the awareness of the people expressed in Q1 and the answer supported their views.

4. Do you believe in the concept of ‘Family Doctors’? Yes-100% No-0%

The question confirms the faith of the general public in a single medical professional for their treatments.

5. How often do you undergo health check-ups? Once a Year-48% Never-40% Twice a Year-12%

The answer reflects a mixed response of the general public about their own health.

6. Which state in India is famous for Ayurvedic treatments? Maharashtra-0% Goa-24% Rajashthan-0% Kerala-76%

The above answer coveys that people are aware about which state is famous for Ayurvedic treatment.

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7. Which of these is a traditional Indian form of healing? Accupuncture-8% Yoga-84% Reiki-8%

The answer above conveys that the general public has awareness about the traditional methods of healing that are currently in demand amongst the popular states of India.

8. How would you grade these hospitals of Mumbai from 1 to 4? Hinduja Breach Candy Lilavathi Tata Memorial

In this case 40% f the people have rated Breach Candy hospital as the No.1 hospital which shows that people are aware of the standards of the hospitals in their city.

9. Unfortunately, if anybody in your relation faces a major ailment would you suggest him/her to undergo treatment in a foreign country? Yes-72% No-28%

The above answer expresses that Indians have a fair amount of faith in India’s healthcare system.

10. Do you think India has the potential to become a forerunner in ‘Medical Tourism’? Yes-56% No-44%

This answer has evoked a feeling of mixed response among the general public about India’s capacity to become a good healthcare destination.

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POTENTIAL OF INDIA IN AREA OF MEDICAL TOURISM AND STEPS TAKEN
A nice blend of top-class medical expertise at attractive prices is helping a growing number of Indian corporate hospitals lure foreign patients, including from developed nations such as the UK and the US.

If a liver transplant costs in the range of Rs 60 lakh-70 lakh in Europe and double that in the US, a few Indian hospitals, such as Global in Hyderabad, have the wherewithal to do it in around Rs 15 lakh-20 lakh. Similarly, if a heart surgery in the US costs about Rs 20 lakh, the Chennai-headquartered Apollo Hospitals Group does it in roughly Rs 2 lakh.

As more and more patients from Europe, the US and other affluent nations with high medicare costs look for effective options, India is pitted against Thailand, Singapore and some other Asian countries, which have good hospitals, salubrious climate and tourist destinations.

While Thailand and Singapore with their advanced medical facilities and built-in medical tourism options have been drawing foreign patients of the order of a couple of lakhs per annum, the rapidly expanding Indian corporate hospital sector has been able to get a few thousands for treatment.

But, things are going to change drastically in favour of India, especially in view of the high quality expertise of medical professionals, backed by the fast improving equipment and nursing facilities, and above all, the cost-effectiveness of the package, said some of the hospitals Business Line spoke to.

The Apollo Group, Escorts Hospitals in New Delhi and Jaslok Hospitals in Mumbai are to name a few which are established names even abroad. A list of corporate hospitals such as Global Hospitals, CARE and Dr L.V. Prasad Eye Hospitals in Hyderabad, The Hindujas in Mumbai, etc also have built capabilities and are handling a steadily increasing flow of foreign patients. "India has much more expertise than say Thailand or Malaysia. The infrastructure in some of India's hospitals is also very

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good. What is more significant is that the costs are much less, almost one-third of those in other Asian countries," says Dr K. Ravindranath, who returned from abroad to start Global Hospitals, which has facilities for liver, kidney and heart transplantations.

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 may become a preferred medical destination. This can be done through an orchestrated effort by the Centre, airlines, travel houses, insurance companies, tourism sector and healthcare providers, says Ms Anjali Kapoor, Head-International Marketing of Indrasprastha Apollo Hospitals, New Delhi.

While accreditation from an international body such as the Joint Commission International (JCI) facilitates better response from Europe and the US, recognition from the National Health Services (NHS) ensures international standards in terms of patient care, quality improvement and patient safety. The Apollo Hospitals Group is in the process of getting accredited with JCI, she said.

Indian corporate hospitals excelled in cardiology and cardiothoracic surgery, joint replacement, orthopaedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few, said Dr Ravindranath.

The CARE Hospitals, which has specialised in heartcare, has concentrated on drawing patients from the Gulf and at least 50 were treated last year, said a hospital spokesperson.

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. In fact, priority treatment is provided today in Indian hospitals.

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MEDICAL TOURISM MAY GENERATE RS.100 BN BY 2012: STUDY
Medical tourism could help upmarket tertiary hospitals gain additional revenues of Rs. 50-100 billion ($1.1-2.2 billion) by 2012, said a new industry study released on April 8.

The study by Confederation of Indian Industry (CII) and consultancy firm McKinsey said India has immense potential to benefit from medical tourism as healthcare costs skyrocket in the developed world.

"In comparison to most developed countries such as Britain or the U.S., treatments like those for dental problems or major procedures like bypass surgery or angioplasty come at a fraction of the cost in India," said Naresh Trehan, chairman of the CII National Healthcare Committee.

Similarly, cardiac surgery in India costs one-tenth of that in the U.S., he said. "Given the potential, medical tourism could account for 3 to 5 percent of the total healthcare delivery market, provided the industry re-orients itself to attract foreign patients," said the study. Infrastructure for hospitals, speciality tourist packages to include medical treatment and promotion of hospital accreditation and standardisation are some of the prerequisites needed to realise the potential.

"The hospitals would have to provide state-of-the-art facilities and improve the quality of in-patient care and service to make the overall experience attractive to foreign tourists," the study noted.

According to the report, India, with 1.5 beds for every 1,000 people, is currently far behind China, Brazil and Thailand with an average of 4.3 beds for every 1,000 people. The study projects that changing demographic and disease profiles and rising treatment costs will result in healthcare spending more than doubling over the next 10 years. Private healthcare will be the largest component of this spending, rising to Rs. 1.56 trillion by 2012, up from the current Rs. 690 billion. This could rise by an additional

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Rs. 390 billion if health insurance cover is available to the rich and the middle class, the study said.

In addition, public spending could double from Rs. 170 billion if the government reaches its target spending of 2 percent of the GDP, up from the current 0.9 percent. Along with the expected increase in the pharmaceutical market, the total healthcare market could rise from Rs. 1.03 trillion currently (5.2 percent of GDP) to between Rs. 2.32 trillion and Rs. 3.2 trillion by 2012.

While there is a tremendous stock of intellectual capital in healthcare and with stateof-the-art treatment and world-class surgery available in the country, the system in India faces some lacunae, the CII-McKinsey study added.

"There is a pressing need for qualified specialist nurses and paramedics and qualified hospital administrators. Several private hospitals have invested in nursing education, but are concerned about loyalty as trained nurses often leave India, attracted by the higher wages offered in the Gulf countries."

It said specialist nurse training would become vital as the number of single-super speciality and multi-super speciality hospitals increased. Standardisation and accreditation of hospitals as also better information management are other aspects, the study highlighted.

By efficiently harnessing technology, medical professionals can now consult specialists anywhere across the globe, send images and have video-conferencing to arrive at a decision for complicated cases, it said.

On the importance of health insurance, the study pointed out that the number is rising rapidly from less than 10 percent coverage. "Insurance would be the main driver for raising quality consciousness and increased demand for better standards, hospital accreditation and patient-management information systems."

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Currently, the voluntary health insurance market is estimated at Rs.4 billion but it is growing fast. Industry expects it to touch Rs.130 billion by 2005.

Treatment Costs ($)* * All costs are average estimates - sources Business world PROCEDURE Facelift Hip replacement Open heart surgery Eye US 8,000-20,000 17,000 150,000 3,100 INDIA 10,000-20,000 4,500 5,000-10,000 7,000 SOUTH AFRICA 1,252 6,671 13,333 2,166 THAILAND 2,682 6,900 7,500 730

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MEDICAL TOURISM IS GROWING IN SMALL CITY
LUDHIANA CITY
According to the data, a bypass surgery in England may cost anywhere between Rs 8 to 10 lakh while in India it costs Rs 1.5 to 2 lakh, which, the experts insist, is done with the same technique and methodology as abroad.

With the increasing globalisation and shrinking borderlines, tourism is not the only budding industry. Now it is skills, techniques, technology and hope that crosses borders with individuals.

Aptly described as ‘medical tourism’, the trend of non-resident Indians visiting their homeland for specialised treatment as well as other benefits is fast catching up in the country with Ludhiana serving as an epicentre owing to its specialised medical services. According to doctors, the reason for a shift in preference to India in terms of medical benefits can be attributed to the fact that the expenditure incurred here for a specific treatment is almost one tenth of what it may cost overseas, especially since the expertise and the treatment meted out in India is of international standards. ‘‘I think the fact that the doctors have achieved the international level of competence and are capable of conducting specialised surgeries has attracted the patients here,’’ said Dr Kim Mammen, Head of Department of Urology, CMC. According to the data, a bypass surgery in England may cost anywhere between Rs 8 to 10 lakh while in India it costs Rs 1.5 to 2 lakh. Similarly, an MRI test of brain costs approximately 750 pounds abroad as opposed to a mere Rs 3,000 here, which, the experts insist, is done with the same technique and methodology as abroad.

According to Dr Mammen, the Urology Department in CMC on an average receives four to five NRI patients a month, usually for prostrate operation, urological cancer, management of stone diseases and reconstruction purposes. He also mentioned that the patients hail mostly from Canada and the UK, as these countries house a major proportion of NRIs who otherwise belong to Punjab. The other reason cited by him for choosing Ludhiana over a treatment overseas by the patients being the long-

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waiting period usually given to them at the hospitals abroad. Dr Mammen had recently operated upon two NRIs based in Canada.

Dentistry is another branch of medical science that has many takers abroad owing to two reasons. Firstlym owing to the high cost involved in a dental check-up as well as the fact that it is not covered under the health insurance scheme of the governments. According to Dr Vivek Saggar, dentist, who runs a clinic in the city and has been advocating the cause of medical tourism, apart from the specialised treatments, the overseas patients also come to get their regular dental check-ups done. ‘‘Not only is the cost one tenth but the fact that here we talk about the problem first and insurance later, makes it a more comfortable option as well,’’ he said.

According to Dr Sandeep Puri, Medical Superintendent, DMC, though the hospital has been receiving calls from NRIs enquiring about the specialised services pertaining to dialysis and other specialised services, it is yet to execute its plans on medical tourism. ‘‘Though we have routine NRI patients complaining of medical problems encountered on their visit to the city, we are yet to put together the plans on medical tourism,’’ he said. For Hari Narayan Singh, an NRI based in Canada, who had come to the city to get treated for enlarged prostrate and utheral stricture, a visit here has saved six months of pain and burden of a due operation. ‘‘If I had not come to CMC, I would have had to wait for six months to get operated upon in Canada,’’ he said. Similar is the experience of S.S. Grewal, also an Indian based in Canada, who is in the city to get treated for a cancerous growth.

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MEDICAL TOURISM TO CURE AILING INBOUND SECTOR
Medical Tourism Tops FICCI Agenda The Federation of Indian Chambers of Commerce and Industry (FICCI), Western Region Council (WRC) has set up a task force for the promotion of medical and health tourism in the state of Maharashtra. Foundations of the project have already been laid, with the task force consisting of the government of Maharashtra, medical education and drugs department of Maharashtra, Maharashtra Tourism Development Corporation (MTDC), travel agents and tour operators and representatives from hospitals and medical research centres.

The aim of this project is to tap the potential of the cost effective medical treatment offered by Maharashtra simultaneously show-casing it as an ideal tourism product. This project will structure special itineraries for both domestic and international tourists who are interested in availing of any kind of medical treatment in the state of Maharashtra. A complete tourism package would be offered according to the destination of the chosen hospital or medical centre where the treatment would take place. Transport facilities including land and air arrangements, hotel accommodation, etc will also be looked after. Sight seeing tours of noted tourist attractions of that destination would be part of the itinerary for those wishing to combine their treatment with leisure. These customized packages aim to optimize the value gained by the tourist by delivering dual benefits of medical facilities along with a leisure holiday plan.

Says wing commander Anil M Gadkary, director, FICCI (WRC), “This is our dream project and we hope to get the support of all the service providers of the industry. This project indeed will give a major boost to the tourism and hospitality industry of Maharashtra. We have received a positive response from MTDC who will jointly work with us on this promotion.”

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FICCI’s Focus on Medical Tourism
It is indeed gratifying to note that well established chambers of commerce are now seriously looking at medical tourism and in fact, the Federation of Indian Chambers of Commerce and Industry, Western Region Council (FICCI-WRC) has taken the lead by setting up a task force for the promotion of health and medical tourism in Maharashtra.

This task force has representatives from the Maharashtra government, the medical educational institutions and the drugs department, Maharashtra Tourism Development Corporation, pharmaceutical companies, travel agents and tour companies. Wing Cdr Anil M Gadkari, director, FICCI-WRC explained, "This is our dream project and we hope to get the support of all service providers of the industry. This project will indeed give a major boost to the tourism and hospitality of Maharashtra. We have received a positive response from MTDC who will work with us on this promotion."

Medical Tourism - winning hearts overseas
Through the last few years tourists have been coming for rejuvenation packages to Kerala or Goa. So far it’s been mainly the non-resident Indian. The effort now is to institutionalise and re-route patients from foreign markets to Indian hospitals - it works out to onefifth the UK rates or one-tenth US prices. A patient can even enjoy the facilities of a hotel, for instance, during the recuperation period or post-operative care.

Indraprastha Apollo Hospital's, Managing Director, Dr Yogi Mehrotra, said that the group has already treated about 60,000 foreigners. Indian surgeons are internationally reputed and Indian medical institutions are already seeing patients from Turkey, Egypt, South Africa, Kenya, Tanzania, Sudan, Ethiopia, Mauritius, some European countries and Seychelles. According to the McKinsey study on healthcare, the medical tourism industry could generate revenues to the tune of Rs 10,000 crore by 2012.

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CASE STUDY
Cyril parry waited for a very long time for his turn to come. The 59-year-old retiree from Birmingham, UK, was suffering from rheumatoid-arthritis. He needed a hip replacement operation urgently. He waited patiently though his pain was getting worse and his pain was getting worse and his movements increasingly restricted. Unfortunately, parry was stuck at the end of a very long queue. The overburdened National Health Service orthopaedic surgeons in the UK were booked solid – for several years. Finally, Parry was told that his turn would come four years and nine months down the line. That was when Parry started surfing the net to see if he could get his hip surgery done elsewhere in the world. After a full year of research, he shortlisted two destinations: a hospital in Thailand and Apollo speciality Hospital, Chennai. In November this year, Parry opted for the latter because, at £4,000 (excluding airfare but inclusive of a 10day stay, post-operative care and a full health check-up), it was almost £5,000 cheaper than the Thai option. It was ironic that Parry needed to travel abroad for his treatment. He was, after all, undergoing a procedure called the ‘Birmingham Hip Resurfing’ – a new technique considered as a superior alternative to the full-hip replacement surgery, and named after the city it was pioneered in. It was perfected at the royal Orthopedic Hospital in Birmingham as recently as 1998. Cyril Parry needed to travel because of the healthcare system followed in the UK which is creating long waiting lists of patients in that country. More on that later. But long waiting lists are not the only reason that there’s been a huge surge in medical travel globally in recent years. Patients from rich countries in the Middle East travel to the US when they need top notch developing nations such as Nigeria or Bangladesh travel to their more developed neighbours for medical treatment because there aren’t enough good facilities available in their own countries. Thousands of Japanese citizens seeking medical treatment fly abroad because of the prohibitive costs of treatment in their home country. Americans seeking cosmetic surgery often fly to South Africa for face tucks and breast augmentation because their insurance coverage doesn’t pay for those – and it is cheaper to get them done in South Africa than back home.

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NEW EMERGING DESTINATION OF MEDICAL TOURISM OTHER THAN INDIA
JORDAN THE FRIENDLY NEIGHBOURING DOCTOR
Jordan stumbled upon the medical travel opportunity quite by accident. After 9/11, it found that a vast number of patients from its neighbouring countries, who had otherwise been traveling to the US for treatment, started coming to Jordan.

That was when this Middle Eastern country launched a massive investment progamme to upgrade and modernize its public hospitals and medical schools. It helped that Jordan already had fairly good healthcare infrastructure, especially when compared with its neighbours.

With around 10000 doctors, 33 private hospitals and 2000-odd beds, it is unlikely that Jordan will be a really big healthcare destination of the like of, say, Thailand, or even India. But what matters is that Jordan attracts a lot of Arab Patients from nations like Yemen, Oman and Syria. They come in for everything from infertility treatments to organ transplants. So, even though Jordan treated only 126,000 or so foreign patients last year, it earned almost $500 million – roughly the amount that Thailand earned from 800,000 medical travelers.

Two years ago, Jordan set up a special counter at its Queen Alia International Airport to meet Arab patients and offer them a string of free services including transportation to hospitals. A Jordanian minister in an interview sometime back pointed out that when Arab patients come to Jordan for treatment, they typically come with their families. That is why everyone – from hotels to taxi drivers – benefit from medical tourists. Jordan has now set a target of $1billion from medical travel in the next couple of years. It is likely to have competition from its neighbours though. Both Saudi Arabia and Bahrain are also seriously looking at the medical travel opportunity.

THAILAND A MAKEOVER FOR THE MAKEOVER EXPERT
Even five years ago, Thailand’s claim to fame in the medical travel world was as a cheap and reliable destination for sex change operations. Over the past few years, the ..60..

Thai government and half a dozen private hospitals have gone into overdrive to change that image. They are now repositioning Thailand as Asia’s premier healthcare hub for everything from cosmetic surgery to hip replacements. The Thai Ministry of Public Health is working closely with the Thai Ministry of Tourism to promote medical tourism in Thailand. More interestingly, the Thai minister met his counterpart from Malaysia a few months ago to see if the two countries could mount some sort of joint-promotion to beat competition from other countries. But the government initiatives pale before the kind of action that the private hospitals are taking to attract medical travelers. Bangkok’s Bumrungrad Hospital is by far the clear leader in the field. With 554 beds on offer, it treated 300,000 plus expatriates and foreigners last year. In fact, a full 25% of all the patients that the hospital treats today are foreigners. To make itself attractive to foreigners, Bumrungrad offers a host of facilities. It offers assistance in 13 languages and it has got itself accredited from the JCAHO, an international certification recognized by most of the big insurance companies. It’s even got a McDonald’s and a starbucks coffee shop in its compound to cater to the tastes of its foreign patients and their companions. “To facilitate patients, we have opened offices in Myanmar, Vietnam, Nepal, Sri Lanka, Maldives, Cambodia, the Netherlands and the Middle East,” says Carl Schroeder, CEO, Bumrungrad Hospital. The other private hospitals aren’t sitting still either. The Phyathai hospital is hiring teachers from the British Council to train its staff, including the maids. It has also signed contracts with hospitals in the Netherlands and Bangladesh to bring in patients awaiting heart surgery there. Thailand provides specialized medical clinics, skilled nursing care, long-term care, nursing homes and rehabilitation clinics at costs that are a fraction of what it would cost in US or Britain. “The cost of treatment in Thailand is less then half of what other neighbouring countries charge,” says Surapong Ambhanwong, chief medical officer of Phyathai 1 hospital.

The Japanese still form the biggest chunk of medical travelers coming to Thailand, though the Americans and the British are now coming in significant numbers. After 9/11, it also got a huge share of the Arab traffic.

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INDIA FAR CHEAPER THAN THAILAND
Today, the medical tourism market in India is worth US$ 333 million.

A liver transplant costs US$ 500,000 in the west, in Delhi, it is being done for US$ 40,000. Cost of medical treatment in India across a whole category of surgeries is substantially lower than Thailand.

It is the next big success story out of India. Five years ago, less than 10,000 patients visited India for medical treatment. Today, the medical tourism market in India is worth US$ 333 million with about 100,000 foreign patients coming in every year. Apollo Group Chairman Pratap Reddy estimates that one out of every ten patients treated at his hospitals is from overseas and with an annual growth rate of 30 per cent, India is already inching closer to Singapore, an established medicare hub that attracts 150,000 medical tourists a year.

Hospitals in India are doing the latest surgeries, at low cost. In the west, a bone marrow transplant costs US$ 400,000. A similar transplant in Chennai costs US$ 30,000. A liver transplant costs US$ 500,000 in the west, in Delhi, it is being done for US$ 40,000.

An MRI of the wrist, for instance, costs just US$ 155 in India while the same can set a patient back by US$ 1600 at a private hospital in Hong Kong.

An open-heart procedure at a top hospital in the country would cost the patient around US$ 5000 as against US$ 50,000 abroad. Similarly, neurosurgery in the country costs around US$ 8,000 as compared with US$ 29,000 in the US. A root canal procedure by a dentist in Mumbai would cost about US$ 20 as against US$ 100 in the US. Also in the US, a knee joint replacement would costUS$16000 in the US as compared to US$ 4500 in India.

India and Thailand are being portrayed as emerging global hubs for low cost medical care. Media prefers to put India and Thailand in the same cost bracket. Yet, a careful scrutiny of expenses in both countries shows that the cost of medical treatment in

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India across a whole category of surgeries is substantially lower than Thailand. Thailand has a cost advantage over India in only two categories: plastic surgery and breast augmentation. India is cheaper than Thailand across a whole range of other, and more serious, surgery categories as the following chart shows.

INDIA IS FAR CHEAPER THAN THAILAND SURGERY Bone Marrow Transplant Liver Transplant Open Heart Surgery (CABG) Hip Replacement Knee Surgery Hysterectomy Gall Bladder Removal THAILAND 62500 75000 14250 6900 7000 2012 1755 INDIA 30000 40000 4400 4500 4500 511 555

*All figures in US$. The Indian costs are based on the average rates offered by top Indian hospitals like Escorts Heart Institute, Apollo Hospitals and Batra Hospital. The Thailand rates are based on rates provided by Bumrungrad Hospital, Bangkok, which is Thailand's largest private hospital.

A joint study by the Confederation of Indian Industry and McKinsey & Co. shows that at the current pace of growth, healthcare tourism alone can rake in over US$ 2 billion as additional revenue by 2012. The Government of India seems to be going along with this projection. In March last year, Finance Minister Jaswant Singh spoke about making India a global health destination, and listed a slew of economic incentives for private hospital groups to create and upgrade infrastructure, as well as reduce their operational costs. He provided tax sops to financial institutions lending to private groups setting up hospitals with 100 or more beds. He also increased the rate of depreciation from 25 per cent to 40 per cent for life-saving medical equipment. Now, state governments, private hospital groups, and even travel agencies have all cottoned on to the trend. • For example, leading Indian travel houses like Sita and Kuoni have launched tie-ups with overseas players that focus on medical tourism.

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• The Karnataka Government is setting up Bangalore International Health City Corporation, which will cater to international patients for a wide variety of health care products and treatments.

• The Asian Heart Institute at Mumbai's Bandra-Kurla Complex, offers state-of-the art facilities for all types of heart complications. It has been set up in collaboration with the Cleveland Institute, USA and offers 'five-star' services at a reasonable cost. While people have long travelled to Thailand for nose jobs, tummy tucks and breast enhancement, India is creating a niche to emerge as a hub for life-saving surgery. And though the bulk of the demand comes from the 20 million strong Non Resident Indian community, India can attract ethnic foreigners in large numbers if it manages to effectively market its strengths abroad. Besides low costs, there are two other unique selling propositions that India has to offer: 1. High success rates 2. Growing credibility.

Indian specialists have performed over 500,000 major surgeries and over a million other surgical procedures including cardio-thoracic, neurological and cancer surgeries, with success rates at par with international standards. The success rate in the 43,000 cardiac surgeries till 2002 was 98.5 per cent. India's success in 110 bone marrow transplants is 80 per cent. The success rate in 6,000 renal transplants is 95 per cent. India's independent credit rating agency CRISIL has already assigned grade A rating to super specialty hospitals like Escorts and multi specialty hospitals like Apollo But the fact is that it is international credibility that counts more in the medical tourism sweepstakes. NHS of the UK has indicated that India is a favoured destination for surgeries. The British Standards Institute has now accredited the Delhi based Escorts Hospital. Apollo Group - India's largest private hospital chain and Escorts Hospital are now seeking certification from the US based Joint Commission on Accreditation of Healthcare Organisations. Without doubt, India is not about nip and tuck medical tourism. It's about making a real difference in the global healthcare value chain.

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GOVERNMENT LAUNCHES MEDICAL TOURISM COUNCIL
What do you get if you combine Ajanta-Ellora, Mahableshwar and the Konkan coast with 20,000-odd medical specialists and hi-tech tertiary care hospitals? Answer (according to the Maharashtra government): a medical tourism haven.

Hooked on to the idea of making the state a medical tourism hub, the Maharashtra government, in collaboration with FICCI (Western Region Council), began working on idea around eight months ago. On November 19 of 2003, the Medical Tourism Council of Maharashtra (MTCM) was formally launched at a function at which health minister Digvijay Khanvilkar, chief secretary Ajit Nimbalkar, Principal Secretary, medical education & drugs department, G.S.Gill, FICCI-WRC chairman Sushil Jiwrajka and Union minister of state for commerce and industry S.B.Mookherjee were present.

Speaker after speaker outlined the fact that Maharashtra had a winning combination of prime tourist destinations and world-class healthcare facilities, which made it a great choice for a medical tourist centre. Pointing out that healthcare, from a simple root canal to open-heart surgery, was available in India at one-fifth the cost of western countries, Mr. Gill declared that MTCM would work on leveraging this advantage. “A CII-McKinsey report had stated that the medical tourism industry could be expected to grow at 30 per cent per year from 2000 onwards,” he said. “My estimate is that if all goes well, we can earn Rs 10,000 crore annually from medical tourism by 2012.”

Interestingly, it’s not only private hospitals—public hospitals also part of the deal. Mr Khanvilkar declared that the government was putting a lot of effort into upgrading these, and hoped that they would attract the middle-class medical tourist. “Eventually, we hope that the estimated 30 per cent annual growth of medical tourism will go up to 50 or 60 per cent,” said Anupam Verma, honorary secretary, MTCM.

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QUESTION STRAIGHT ANSWERS
DIGVIJAY KHANVILKAR – STATE MINISTER FOR HEALTH, ON LAUNCH OF THE MEDICAL TOURISM COUNCIL OF MAHARASHTRA (MTCM)

The state government has been talking about health tourism for quite a while but nothing has really come of it so far. Will the MTCH yield any results?

We’ll see results soon. Given the involvement of the central and state governments, Federation of Industrial Chambers of commerce and Industry (FICCI), health tourism will definitely take off. This is only the starting point. Mumbai and Maharashtra have some of the best doctors and by upgrading existing facilities it is possible to have an excellent health tourism programme in place.

How much revenue is it likely to generate?

At this moment, it’s difficult for me to give an estimate.

Will medical tourism promotion be restricted to private hospitals or will public hospitals be brought under its purview?

Public hospitals will also come under medical tourism. As a matter of fact, we have excellent facilities in places—like in Pune, Kolhapur and Mumbai. By upgrading facilities, public hospitals can be very much part of medical tourism. Besides, they have excellent staff.

Isn’t it a bit far-fetched to have patients who come for treatment go for short holidays nearby?

We have our rural and primary healthcare facilities very much in place, which should be able to take care of things. If necessary, we can fly them down to major medical establishments.

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Don’t you think that more than launching websites and road shows abroad to promote health tourism, the need of the hour is aggressive marketing and up gradation of facilities?

Marketing is indeed very important and we’ll be doing it. But we are working towards improving our medical facilities.

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CONCLUSION
COUNTER-PLAN
(To tap medical tourism in India)

A $40 billion plus market worldwide growing at over 20% a year throws up huge opportunities for anyone smart enough to tap it. India has the entire base and infrastructure required to build-up a strong brand value for itself amongst the international community as a top class healthcare destination. But now depends wholly on how the coordination takes place to tap-in this sector. Some following conclusions as seen after reviewing the entire healthcare situation in India by me can be considered as important steps to improve the Indian ‘Medical Tourism’ situation. 1. There should be a central regulatory authority to plan-up the Infrastructure development and other issues regarding medical tourism. 2. The sector of medical tourism should be regarded as a totally separate entity other than the regular tourism activities by the central regulatory authority. 3. There should be no sort of red-tapism involved in this sector In the true sense of the word. 4. A great edge has been provided to India by the private sector which has professional management. This sector should be secured respectfully and should be boosted through attractive incentives by government authorities to achieve high valued profits. 5. A study showed without any concentrated and combined efforts up to 1 lakh plus medical travelers visited India during the last year. This shows that there should be a real concerted effort by each segment of the Indian medical sector-Indian. 6. The biggest reason why people travel to India for treatments are the comparatively low cost which should be maintained throughout. 7. India should be marketed as a ‘Healthcare Destination’ projecting its conventional as well as traditional methods of healing and treatments. 8. India should also attract hordes of tourists by providing information to the foreign medical tourists about the very low costs offered for various treatments through various mediums. 9. Along with these efforts the places of tourist interests in and around the medical destination should be developed well to increase the tourist influx to such places.

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10. Various competent hospitals should work according to the international standards & should try and acquire international certification and accreditation.

Thus all in all for the sector of medical tourism to come out in flying colors India needs to develop products related not only to healthcare but also tourism. But they should have a UPS and be cost advantageous. Interaction with foreign patients will also improve the quality & the costs of treatment.

HEALTHCARE
The size of India’s healthcare industry is worth US$ 20 billion. In India, 12 per cent of the national annual expenditure is on healthcare. Of this, 82 per cent of the total health expenditure comes from the self-paid category, while employers account for 9 per cent and insurance covers 5 per cent of the total healthcare expenses. India’s expenditure on health is relatively high when compared to other developing countries. The chart on left compares India’s expenditure to other countries. The rise in the literacy rate, higher levels of income and an increased awareness through enhanced media campaign has led to health receiving greater attention and a preference for private services.

Private Health Care Private health care may be classified into various levels, based on the scale of operations and the range of services provided. Some of these are listed below: • Individual private practitioners providing medical prescriptions and basic healthcare services; • Small nursing homes with bed capacity ranging from 5-100 beds primarily concentrated in urban areas

As per the 52nd Round of National Sample survey Organisation, 81% of the outpatient care and 56% of inpatient care is being provided by the private sector in the country.

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Large hospitals run by trusts or corporates that are located primarily in cities and towns across the country. The 1990s have seen significant entry of Indian companies in medical care. Most of these players have focused on large, single or multi-specialty facilities located in large cities. These include Apollo, Fortis, Max, Wockhardt and Escorts, among others.

Leveraging India’s IT strengths, telemedicine is being tried out at a few hospitals. This holds promising potential for providing quality medical care even in remote parts of the country.

Opportunities • Healthcare is expected to be one of India’s largest industries in the near term with present growth rates of around 13 per cent annually. Further, India needs to add 80,000 hospital beds a year for the next 5 years according to a WHO report. • The opening up of the insurance sector to private players is expected to further boost the healthcare industry. Health Insurance will make healthcare affordable to a large number of people. • There is an increasing preference for private medical care amongst the urban population. • The National Health Policy (NHP) – 2002 announced by the Government envisages increasing public health investment to 2% of GDP by the year 2010 from the existing level of 0.9% and the total health investment to 6% from the current level of 5.2%. The NHP-2002 welcomes the participation of the private sector in all areas of health services-primary, secondary and tertiary.

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BIBLIOGRAPHY
Newspapers
1. Times of India 2. Economics Times

Magazines
1. Business world

Websites
1. www.ourworld.compuserve.com 2. www.mohfw.nic.in 3. www.cehat.org 4. cities.expressindia.com 5. www.expresstravelandtourism.com 6. www.pd.cpim.org 7. www.cbc.ca 8. www.apollohospitals.com 9. www.ibef.org 10. www.cbc.ca 11. www.Tata-AIG Hospitals.com 12. www.Tata-AIG Hospitalsdelhi.com 13. www.Tata-AIG Hospitalspune.com

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