PREFACE

Good Health is a chariot of mental and physical peace which takes you towards the path of success, happiness and prosperity Tourism Industry around the world is growing with the developing horizon contributing 9% to the world GDP and facilitating 1,035 tourist globally. Among the several branches of this flourishing tree Medical Tourism is the one that is emerging as a strongest bud of prosperity and wellbeing for the entire ecosystem of Tourism Industry. The term medical tourism is often used in the context of patients traveling abroad for medical care to countries such as Mexico, Costa Rica, India, Thailand and Singapore - and this is certainly true. However, there is also a growing trend towards domestic medical tourism, in which patients travel from one area of the country to another for medical care. Regardless of the reason, the common denominator in all medical tourism related activities is that patients are traveling away from their home region to access these services. "Whether it is affordability, accessibility, availability or better quality, in the final analysis, patients are searching for better perceived value." Medical tourism is not a new phenomenon. In fact, archaeological evidence from the third millennium B.C. suggests that ancient Mesopotamians traveled to the temple of a healing god or goddess at Tell Brak, Syria, in search of a cure for eye disorders. A few thousand years later the Greeks and Romans would travel by foot or ship to spas and cult centers all around the Mediterranean. The Asclepia Temples, dedicated in honor of the Greek god of medicine, were some of the worlds first health centers. Pilgrims would sometimes spend several nights in the temple, hoping Asclepios would appear in a dream and suggest a diagnosis or treatment. Later in the 16th and 17th centuries, spa towns such as St. Moritz and Bath became prime destinations for the European upper classes looking to soothe their ills. More recently, the wealthier citizens of underdeveloped nations have begun traveling to renowned medical institutions in the United States or Europe, usually for invasive medical procedures such as open heart surgery or cancer treatments that require a high degree of specialization and experience. Over the last fifteen years, however, the trend has reversed itself as increasing numbers of patients have begun traveling from developed nations such as the United States and Canada to so called underdeveloped nations in search of affordable medical care or treatment options not available at home. Most media attention has focused often in a negative light - on patients traveling for what are referred to as elective procedures such as plastic surgery or dental. However, a growing number of patients are traveling for more acute care procedures such as open heart surgery, spinal procedures or hip and knee replacements. A rapidly aging U.S. population coupled with escalating healthcare costs and the uncertainty of healthcare reform are expected to increase medical tourisms appeal even further. Patients from all walks of life and from many regions in the U.S. and abroad are currently traveling for medical care. The global medical tourism industry is growing by 20 - 30% annually. Every year, about 7 million people grab their passports and fly abroad looking for quality, affordable medical care everything from dental work to weight-loss surgery to cancer treatment. That's fuelling an industry worth as much as $40 billion According to the World Travel & Tourism Council (WTTC), medical tourism contributed 9 percent of global GDP (more than US$6 trillion) and accounted for 255 million jobs in 2011.

Source: http://www.kpmg.de/

60% of clinics, hospitals and medical tourism reported growth in international patient numbers over the last 12 months. 23% saw no increase and 17% experienced a decline. 80% expect their international patient numbers to grow over the next 12 months. 49% expect annual growth of more than 10% pa in the medical tourism market over the next five years. Over the next five years, cosmetic surgery is seen as the biggest growth area for medical travel (cited by 56% of respondents), with dental treatment (43%), cancer treatment (43%) and infertility treatment (40%) also expected to experience significant growth. Leading destinations in terms of quality and range of services provided to international patientsUSA, Thailand and Singapore at the top Nearly 80% of demand for medical travel is driven by cost savings. Cosmetic surgery leads all other treatments, representing 38% of demand. About 92% of total spending on medical travel per patient is less than $30,000. Medical tourists spend between $7,475 and $15,833 per medical travel trip. For 6 million patients, medical travel may contribute $45 $95 billion to global GDP. Latin America and Asia are the two leading regions for medical travel. Mexico and India respectively have the highest demand for medical tourism. Almost 76% of patients with a future interest in medical travel are American.
Medical Travelers by Source and Destination Europe Latin America Middle East 4% 1% 1% 10% 5% 13% 12% 8% 2% 26% 1% 2%

To From Africa Asia Europe Latin America Middle East North America Oceania
McKinsey Report

Asia 95% 93% 39% 1% 32% 45% 99%

North America

6% 33% 87% 58% 27%

Asia is one of the leading regions in the world for medical tourism with following facts: Asia medical tourism industry has been growing at the rate of 20% per annually and expected to reach US$ 8.5Billion by 2015. Asia in itself generates revenues in billions and consists of 12.7% of the global market. A growth rate of 17.6% and 23% of revenue growth is expected by 2013. The coalescing of quality healthcare 3

at affordable costs and leisure tourism makes Asia one of the top choice destinations for medical tourists. Asia medical tourist number of arrivals is expected to cross the figure of 10 Million numbers by 2015. Thailand is the leader among the Asian countries, which received maximum number of foreign patients in 2012. India is the second largest player, closely followed by Singapore, Philippines and Malaysia Thailand holding more than 40% share in Asia medical tourist arrivals in 2011. Its medical tourism market is also expected to be more than double by 2015 from its current market in 2011. India was one of the first countries to recognize the potential of medical tourism. From the year 2009 to 2011 the number of medical tourists in India has grown by 30%. It is estimated that by the year 2015, India will receive nearly half a Million medical tourists annually making it a 9,500-crore industry by 2015. Malaysia has seen an impressive growth in medical tourism industry. Malaysia medical tourism market has grown more than 8 times in 2011 compared to its market in 2003.The international patient arrivals to Malaysia are expected to grow with a CAGR of 29.27 percent for the period of 2009 to 2013. Singapore medical facilities are considered to be the best in Asia but its treatment cost are bit costlier compared to its competitors. Singapore medical tourist arrivals are expected to be more than 1 Million by 2015. Philippines started off bit late for the medical tourism but are catching up quickly. Its medical tourism market is expected to grow with a CAGR of 9% for the period of 2012 2015. South Korea is a fast-growing medical tourism destination. It is forecasted that by 2015, South Korea will attract more than 300 Thousand medical tourists. Taiwan medical tourism has become one of the biggest attractions for mid to high income Chinese tourists. The country's medical tourism market is expected to increase at 7% CAGR from 2012 to 2015.

Present scenario of Indian medical Tourism Industry Statistics suggest that the medical tourism industry in India is worth $333 million (Rs 1,450 Crore) while according to the study by CII-McKinsey, country had earned Rs 5,000-10,000 crore in 2012. Medical Tourist in India

Number of Medical Tourist

3500000

Number of Medical Tourist

3000000 2500000 2000000 1500000 1000000 500000 0 2005 2008 2011 2015

Years

Revenue Earned
14000 12000 12000 10000 8000 6000 4000 2000 0 2013 2015 7500

Employment Scenario: Presently, in India, the healthcare sector has an estimated revenue of around $30 billion constituting 5% of GDP and offering employment to around 4 million people [Source: Confederation of Indian Industry (CII)].

All the above finding makes it clear that there is a tremendous scope of medical tourism industry to grow beyond its peripheries, what require is to explore it properly and to make aware all the directly and indirectly associated communities with the changing trends of this booming industry. NIMA takes the opportunity to present this compilation after gathering all the information related to Medical Tourism (secondary research) including basic concepts of health wellbeing and medical tourism, Global, Asian and Indian Scenario, SWOT analysis of India as a medical tourism destination, understanding the medical tourism system and developing business in India ,best super speciality hospitals in India, prospects and challenges for tourist visiting India for medical tourism, skills required for medical tourist facilitators and future trend in medical tourism industry compiled in nine chapters for the reader. Every Chapter takes the reader towards the basic understanding of the current and emerging trends of medical tourism Industry with major emphasis on Indian perspective.

Crores

Compilation By: NIMA (North India Management Association) Research Team

CONTENT
CHAPTER 1 TOPIC Concept of Health, Wellness and Medical Tourism Industry 2 Present Scenario and Growth Patterns of Medical Tourism Industry in World - Major Medical Tourism generating Countries - Most Travelled Destinations in the World for Medical Tourism 3 Medical Tourism in Developing Asian Continent - Major Treatments under Medical Tourism - South Asia - South East Asia 4 India: A Hub for Healthcare - Introduction - SWOT Analysis - Major Areas of Healthcare - Major Health Hubs in India - Government Initiatives 5 Understanding the system of Medical Tourism Business in India 6 Latest developments in Medical Tourism Industry in India 7 Medical Tourist visiting India: Prospects and Challenges - Ethical Issues - Smart Health Travelers: Dos & Donts 8 9 Skills Requirement in Medical Tourism Industry Future Trends in Medical Tourism Industry
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CHAPTER-1 CONCEPT OF HEALTH, WELLNESS AND MEDICAL TOURISM

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. World Health Organization

Health and wellness covers a broad range of aspects, from healthy diets and healthy lifestyles to personal care and hygiene, with the aim to contribute to the physical, emotional, spiritual, intellectual and sustainable well-being of consumers, employees, their families and the communities Wellness and Health tourism involves people who travel to a different place to proactively pursue activities that maintain or enhance their personal health and well-being, and who are seeking unique, authentic, or location-based experiences that are not available at home. The world population is aging and becoming more affluent at rates that surpass the availability of quality healthcare resources. In addition, out-of-pocket medical costs of critical and elective procedures continue to rise, while nations offering universal care are faced with ever-increasing resource burdens. These drivers are forcing patients to pursue cross-border healthcare options either to save money or to avoid long waits for treatment. Worldwide medical tourism market is growing at a rate of 15-25%, with rates highest in North, Southeast and South Asia. Market size is USD 24-40 billion, based on approximately eight million cross-border patients worldwide spending an average of USD 3,000-5,000 per visit, including all medically-related costs, cross-border and local transport, inpatient stay and accommodations. An estimate of 900,000 Americans will travel outside the US for medical care this year (2013). Medical tourism refers to the growing practice of traveling across international borders in order to get health care or medical attention. Thus, medical tourism is part of the tourism industry which definitely has a big impact on the economies of destination countries. The most common medical treatment or procedures involved are elective procedures and complicated specialized surgeries like joint replacement, heart surgery, dental surgery, bariatric surgery or weight reduction surgery and cosmetic surgery.

A specialized set of medical tourism is the reproductive tourism which refers to the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy as well as other assisted reproductive technology treatments. More and more countries are becoming medical tourism destinations. Medical tourism statistics revealed an anticipated growth of the industry from about $40 billion in 2004 to $100 billion in 2012. . Every year, about 7 million people fly abroad for quality, affordable medical care everything from dental work to weight-loss surgery to cancer treatment. Globally an industry fueling worth as much as $40 billion every year Using US costs across a variety of specialties and procedures as a benchmark, average range of savings for the most-traveled destinations: Brazil: 25-40% Costa Rica: 40-65% India: 65-90% Korea: 30-45% Malaysia: 65-80% Mexico: 40-65% Singapore: 30-45% Taiwan: 40-55% Thailand: 50-70% Turkey: 50-65%

Health and Wellness Industry

Wellness can be defined as the balanced state of body, spirit and mind, including such holistic aspects as self-responsibility, physical fitness/beauty care, healthy nutrition, relaxation, mental activity and environmental sensitivity as fundamental elements. With more and more people these days focusing their efforts on losing weight, getting fit, and living a healthier lifestyle, many social entrepreneurs are seeking out opportunities in the health and wellness world . The trends all point in a single direction - more and more consumer spending on health and wellness. In fact, it is believed that wellness is the next trillion-dollar industry. Health-related beauty and hygiene lines both yield approximately $200bn per annum, and will enjoy a 6% sales lift each year. On the same terms, personal healthcare generates $85bn, and will improve by a minimum of 3%. Developed economies dominate spending, while emerging ones dominate growth. In 2006, for example, the average Chinese person spent about $60 on health and wellness just about a tenth of that of the average Canadian ($580). But between 2006 and 2015, the expected average annual spending on health and wellness to rise more than 13% for Chinese, compared to 3% for Canadians. That will narrow the spending gap to about four to one. To look at it another way, almost 70% of over-the-counter (OTC) drug sales growth is expected to come from emerging markets, half of that from the BRICs (Brazil, Russia, India, China). The reason is simple: When people have more money, they spend some of it on health. And vast numbers of people are about to hit the level of income where this is happening. In India, for example, the number of households making more than $22,000 a year has quadrupled in the last decade, to almost 4 million. The number making at least $4,400 has almost tripled, to 28.4 million. The additions in just those two categories comprise a population greater than that of Germany. The biggest change is that advancements in science and technology allow the increased personalization of medical care. Global consumers are also ever more open to a broader set of health and wellness solutions, including non-traditional treatments. The sales of herbal remedies are expected to nearly double in next decade; already, the North American market for alternative medicine is $16.4 billion and in Asia more than $30 billion. People are not waiting for expert advice on many health-related decisions. Consumers also have access to more health information than ever; fully 96% of American adults who use the Internet have used it to look up health information. And they are not just looking; they are buying. More than half of French consumers regularly purchase health and beauty online; among Americans, information 8

collected at company/ product websites is the most influential touch point over the purchase decision. About 70% of Chinese consumers research the Web before buying.

Nutrition and Good Health

An individual's food choices depend on energy needs, nutrient needs and enjoyment. Family, friends and personal beliefs, including cultural and environmental considerations, also play a major role in people's food selection. Many genetic, environmental, behavioral and cultural factors can affect a person's health. Understanding family history of disease or risk factors, such as body weight and fat distribution, blood pressure and blood cholesterol, can help people make more informed decisions about how to improve health. Making good food choices is among the most pleasurable and effective ways of improving health. Healthful diets help children grow develop and perform well in school. A healthy diet allows adults to work productively and feel their best. Good food choices also can help to prevent chronic diseases, such as heart disease, certain cancers, diabetes, stroke and osteoporosis that are leading causes of death and disability among Americans. A proper diet can also reduce major risk factors for chronic diseases, such as obesity, high blood pressure and high blood cholesterol. People require energy and certain essential nutrients. These nutrients are essential because the body cannot make these nutrients on its own and must obtain them from food. Essential nutrients include vitamins, minerals, certain amino acids and certain fatty acids. Foods also contain fiber and other components that are important for health. Each of these food components has a specific function in the body and they are all required for overall health. For example, people need calcium for strong bones, for example, but many other nutrients also take part in building and maintaining bones. The carbohydrates, fats and proteins in food supply energy, which is measured in calories. Carbohydrates and proteins provide 4 calories per gram. Fat contributes more than twice as much -- 9 calories per gram -and foods that are high in fat are also high in calories. Alcohol is also high in energy and supplies 7 calories per gram. Healthful diets contain the amounts of essential nutrients and energy needed to prevent nutritional deficiencies and excesses. Healthful diets also provide the right balance of carbohydrate, fat and protein to reduce risks for chronic diseases, and these diets can be achieved through a variety of foods that are available, affordable and enjoyable.

Food Guide Pyramid

The Food guide pyramid was developed by representatives of recognized health and nutrition organizations. It is recommended as a guideline for healthy eating by the American Dietetic Association. The food pyramid is designed to make healthy eating easier. Healthy eating is about getting the correct amount of nutrients protein, fat, carbohydrates, vitamins and minerals you need to maintain good health. GRAINS (Bread, cereal and Rice) 6 to 11 servings/ day: This group is the critical base of the food guide pyramid because it gives carbohydrates, the main source of fuel for the body. They are also rich in fiber , iron and B-Vitamins. Good quality whole grains, bread , cereals ,pasta and other enriched carbohydrates are an essential part of a healthy diet. VEGETABLE GROUP : 3 to 5 servings/day: Vegetables are a terrific source of many nutrients. The most coloured vegetables in diet will guarantee the most vitamins, minerals and cancer preventative substances. Vegetables are also very high in fiber and low in calories FRUIT GROUPS :2 to 4 servings/day :Fruits are a very important source of fiber their juices contain very little fiber. Citrus fruits , berries and melons provide a lot of vitamin c , unless fruits have had extra sugar added , they are generally low in calories. MILK,YOGURT AND CHEESE GROUP:2 to3 servings/day: This food group is the most dependable source of calcium in the diet. MEATS, POULTRY , DRY BEANS, EGGS AND NUTS GROUP:2 to 3 servings/day: It is recommended to have leaner versions of meats and poultry. It is better to prepare these without a lot of extra grease or gravies. FATS AND OILS:Use sparingly/ day: along with sweets, fat and oils are found in the tip of the food guide pyramid, indicating they are to be eaten in moderation. Although no specific number of serving is recommended, it is absolutely necessary to eat fat or oils in moderate amount to maintain energy and health. For healthier heart , most of the fats should be mono unsaturated fats coming from such food as olive oil, olives, nuts and peanut. Intake of animal fats such as dairy fat as in butter , cheese and whole milk, high fat meats and cold cuts should be on the lower side. Trans fatty acids should be especially avoided

Health Tips
A For away- This vitamin and beta carotene help to boost Immunity against disease. It also assists in healing process of diseases. Such as measles. Good Natural source of vitamin A are dairy products, green and yellow vegetables, mango and chilly pepper. 10

Don skip Breakfast Breakfast skippers tend to gain weight. A Balanced Breakfast Include fresh fruit ,a high fiber cereal ,low fat milk or yoghurt , whole wheat toast and a boiled egg. Berries - Blueberries, strawberries and raspberries contain plant nutrient known as anthocyanidins which are powerful antioxidants. Which is believed to help protect against heart disease and cancer I Say Tomato Tomato is a superstar in fruit tomato contains lycopene a powerful cancer fighter . Theyre also rich in vitamin C Eat your stress away- prevent low blood sugar as it stresses you out. Eat regular and small healthy meals and keep fruit and veggies handy . Eating unrefined carbohydrate nuts and banana boosts the formation of serotonin another feel good drug. Load up on vitamin C- we need at least 90 mg of vitamin C per day and the best way to get this is by eating at least five servings of fresh fruit and vegetables everyday so, hit oranges and guavas. Drink plenty of Water Drinking enough fluid helps to flush toxins from your body and keeps you hydrated .The recommended amount of water you should aim to drink everyday is 6 to 8 glasses. GI- Carbohydrate with a high glycaemic index such as Bread, sugar , honey and grains based food will give instant energy and accelerate your metabolism. Eat for Good Vision-Protecting your eyes starts with the food on your plate. Studies have shown that nutrient such as omega 3 fatty acids, vitamin C and E can help lead to good eye health eg- eggs, nuts, beans and oranges. Try to Exercise Regularly- walking is one of the best forms of exercise. It costs nothing and it will help to improve your health and general well being. The list of health benefits that can be gained from taking regular exercise, such as walking , swimming or dancing . Your fitness level will improve. Add Calcium to your diet- Build up Reserves of calcium and strengthen your bones particularly before you are 35 years old Rich source of calcium Include milk, lassi, paneer, dahi, kheer and kulfi. Add Sodium to your diet- A sodium is essential to the body for fluid balance, muscle contractions and nerve reactions but those sufferings from high Blood pressure should have low sodium diet. Eat more healthy carbs and whole grains o Choose healthy carbohydrates and fiber sources, especially whole grains, for long lasting energy. In addition to being delicious and satisfying, whole grains are rich in phytochemicals and antioxidants, which help to protect against coronary heart disease, certain cancers, and diabetes. Studies have shown people who eat more whole grains tend to have a healthier heart. o Healthy carbs (sometimes known as good carbs) include whole grains, beans, fruits, and vegetables. Healthy carbs are digested slowly, helping you feel full longer and keeping blood sugar and insulin levels stable. o Unhealthy carbs (or bad carbs) are foods such as white flour, refined sugar, and white rice that have been stripped of all bran, fiber, and nutrients. Unhealthy carbs digest quickly and cause spikes in blood sugar levels and energy. Enjoy healthy fats & avoid unhealthy fats o Good sources of healthy fat are needed to nourish your brain, heart, and cells, as well as your hair, skin, and nails. Foods rich in certain omega-3 fats called EPA and DHA are particularly important and can reduce cardiovascular disease, improve your mood, and help prevent dementia. Add to your healthy diet o Monounsaturated fats, from plant oils like canola oil, peanut oil, and olive oil, as well as avocados, nuts (like almonds and hazelnuts, ), and seeds (such as pumpkin, sesame). o Polyunsaturated fats, including Omega-3 and Omega-6 fatty acids, found in fatty fish such as salmon, herring, mackerel, anchovies, sardines, and some cold water fish oil supplements. Other sources of polyunsaturated fats are unheated sunflower, corn, soybean, flaxseed oils, and walnuts. Reduce or eliminate from your diet: 11

Saturated fats, found primarily in animal sources including red meat and whole milk dairy products. o Trans fats, found in vegetable shortenings, some margarines, crackers, candies, cookies, snack foods, fried foods, baked goods, and other processed foods made with partially hydrogenated vegetable oils. o Fill up on colorful fruits and vegetables o Fruits and vegetables are the foundation of a healthy diet. They are low in calories and nutrient dense, which means they are packed with vitamins, minerals, antioxidants, and fiber. o Try to eat a rainbow of fruits and vegetables every day and with every meal the brighter the better. Colorful, deeply colored fruits and vegetables contain higher concentrations of vitamins, minerals, and antioxidantsand different colors provide different benefits, so eat a variety. Aim for a minimum of five portions each day. Some great choices include: o Greens: Branch out beyond bright and dark green lettuce. Kale, mustard greens, broccoli, and Chinese cabbage are just a few of the optionsall packed with calcium, magnesium, iron, potassium, zinc, and vitamins A, C, E, and K. o Sweet vegetables: Naturally sweet vegetablessuch as corn, carrots, beets, sweet potatoes, yams, onions, and squashadd healthy sweetness to your meals and reduce your cravings for other sweets. o Fruit: Fruit is a tasty, satisfying way to fill up on fiber, vitamins, and antioxidants. Berries are cancer-fighting, apples provide fiber, oranges and mangos offer vitamin C, and so on. o Put protein in perspective-Protein gives us the energy to get up and goand keep going. Protein in food is broken down into the 20 amino acids that are the bodys basic building blocks for growth and energy, and essential for maintaining cells, tissues, and organs. A lack of protein in our diet can slow growth, reduce muscle mass, lower immunity, and weaken the heart and respiratory system. Protein is particularly important for children, whose bodies are growing and changing daily.

Here are some guidelines for including protein in your healthy diet: Try different types of protein. Whether or not you are a vegetarian, trying different protein sources such as beans, nuts, seeds, peas, tofu, and soy productswill open up new options for healthy mealtimes. Beans: Black beans, navy beans, garbanzos, and lentils are good options. Nuts: Almonds, walnuts, pistachios, and pecans are great choices. Soy products: Try tofu, soy milk, tempeh, and veggie burgers for a change. Avoid salted or sugary nuts and refried beans.

Medical Tourism/Travel
Medical travel is a phrase very much preferred over medical tourism by health care leaders, hospital executives, doctors and other medical professionals. Most have reluctantly accepted the term medical tourism but many continue to dislike it because they feel it trivializes the process of getting and giving treatment and care. Medical travel is a term involving people who travel to a different place; often great distances, to receive treatment for a disease, ailment, or condition, and who are seeking lower cost of care, higher quality of care, better access to care, or different care than they could receive at home. Medical tourism, specifically is to the increasing tendency among people from developed countries to undertake medical travel in combination with visiting tourist attractions. Medical tourism is often seen as adding medical services to common tourism. 12

Interrelatedness of health and medical tourism domains

Invasive vs. non-invasive procedures

Wellness travelers may seek care characterized as non-invasive: alternative therapies and wellness treatments; most dental treatments; some non-invasive cosmetic surgery procedures like Botox, facial fillers, spot liposuction, and fat injections; acupuncture therapy; ayurveda; mineral spas; colonic cleansing; most executive check-ups. It is critical to make a distinction between invasive and non-invasive procedures. Insurance companies that issue medical travel insurance are clear about this. Medical travel insurance different from travel medical insurance which covers tourists for accidental, unplanned medical treatment while on vacation insures against complications of invasive procedures. The U.S. government defines surgical and other invasive procedures as operative procedures in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice. Invasive procedures encompass a range of services, including: Minimally invasive dermatological procedures (e.g., biopsy, excision, or deep cryotherapy for malignant lesions) Extensive multi-organ transplantation All procedures classified as surgery Procedures such as percutaneous transluminal angioplasty and cardiac catheterization 13

Minimally invasive procedures involving biopsies or placement of probes or catheters requiring entry into a body cavity through a needle or trocar

Some very minor procedures such as drawing blood or using certain instruments for examinations are technically invasive procedures but are not included in the definition. Non-invasive procedures sought by wellness travelers are dental treatments (excluding implants), dermatology procedures, certain cosmetic procedures, some ophthal-mology procedures, genetic testing and so on.They may be single-purpose travelers, mostly focused on saving money, who travel across a border and return the same day. They may be on vacation and opt to have some non-invasive treatments at the same time as participating in wellness tourism activities. Medi-spas have emerged to serve these vacationers. Similarly, Europe offers many spas for wellness travelers that traditionally provide healing waters and mineral baths, and are prescribed by medical doctors for rehabilitation. Medical Tourism :An Integrated Model

Characteristics of the medical traveler

Medical travelers have 3 common characteristics: They are not resident in the destination country They travel from home to a different country for care The cultural or social environment and/or language of the medical destination may be different or strange

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They are traveling international patients.

A medical travel journey is distinguished by the following: Advance planning Exchange of medical records and medical history Pre-surgery instructions that may need to be followed prior to reaching the medical destination A procedure that is invasive and/or requires general or twilight anesthesia; or is a major noninvasive treatment (chemotherapy, radiation therapy, etc.) Consideration about the kind of accommodations that will be needed post-surgery Recovery care management Care planning and follow-up upon returning home Possible additional, unexpected medical attention This last item is very important. The medical traveler may acquire an infection, get a complication, or have a bad outcome, likely needing further medical attention. The medical traveler may be required to return to the original place of treatment, or may be able to receive treatment at home. Treatment at home may depend on how medical travel is perceived by the treating doctor at home. Many medical travel patients, or medical travelers, require admission to hospital, whether for ambulatory care and a stay of less than 24 hours, or for inpatient care and overnight stay. Most require light or general anesthesia, administered by a licensed medical professional. Most, if not all, must make their medical travel plans in advance. Seldom does one pop into a hospital or clinic casually for an invasive treatment. Indeed, those who do choose to have an invasive procedure on a whim may be putting themselves in harms way and the facility or doctor who takes them may be negligent 15

Health and medical tourism is a complex area of study. Many governments, international agencies, private health providers and even some medical practitioners see it as a means of economic development that may cross-subsidise domestic health access and provide a competitive cure for the problems facing the global health system (Horowitz and Rosensweig, 2007; Underwood and Makadon, 2010). In contrast, others see it as part of a process of marketisation and economisation of public health services already under pressure from neoliberal political agendas; further reinforcement of the commoditisation of the body; and also reinforcing gaps between have and have-nots both within and between societies.

REFERENCES : 2013 MTA Medical Tourism Survey Report Gawai Consortium(www.gawaiconsortium.com) http://articles.economictimes.indiatimes.com/keyword/medical-tourism http://www.imtj.com/EasysiteWeb/getresource.axd?AssetID=373334&type=full&servicetype=Attac hment http://www.hindu.com/thehindu/thscrip/print.pl?file=2005081602310300.htm&date=2005/08/16/&p rd=bl& http://www.internationalexperts.com/index.php/research/item/medical-tourism-in-india http://www.cdacmohali.in/P_MedicalTourism.aspx Gss_sri_spasand wellnessreport_reb82010_2.pdf Healthcare-telemedicineandmedicaltourisminindia-2.pdf Indianewopportunity.pdf KPMG International Report pub-20120207-issues-monitor-healthcare-medical-tourism-en-pdf Grailresearch-riseofmedical-torism-summary.pdf www.helpguide.org/life/healthy_eating_diet.htm http://www.healthnaturalguide.com/2013/08/healthy-food-guide-what-can-i-eat.html healthandwellness.mycgforum.com-CGF_health and wellness_booklet.pdf

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CHAPTER-2 PRESENT SCEANRIO AND GROWTH PATTERNS OF MEDICAL TOURISM INDUSTRY IN WORLD Overview of Global Medical Tourism Industry
The international healthcare marketplace emerged in the late 19th century when patients from less developed parts of the world with the necessary resources to do so began to travel to major medical centers in Europe and the United States to have diagnostic evaluation and treatment that was unavailable in their own countries. The situation is very different in the medical tourism model, where patients from highly developed nations travel to less developed countries, bypassing medical care that is offered in their own community but is inaccessible or undesirable to them. For patients from highly industrialized nations, the primary reason to have medical services in less developed countries is attractively low cost. Such cost-conscious patients choose to accept the inconvenience and uncertainties of offshore healthcare to obtain service at prices they can more comfortably afford. A patient from the United States is likely to be a middle class adult requiring elective surgical care who has no health insurance or who has inadequate coverage. The other group pursuing medical tourism are people seeking cosmetic surgery, dental reconstruction, fertility treatment, gender reassignment procedures, and other treatments not covered by health insurance. The common feature in both groups is that their resources are adequate to purchase healthcare in low-cost medical tourism destinations but insufficient for them to comfortably have the same services in their local market. For patients from countries where a governmental healthcare system controls access to services, the major reason to choose offshore medical care is to circumvent delays associated with long waiting lists. Patients also travel to offshore medical destinations to have procedures that are not widely available in their own countries. Some patients, particularly those undergoing plastic surgery, gender change procedures, and drug rehabilitation, choose to go to medical tourism destinations because they are more confident that their privacy and confidentiality will be protected in a faraway setting. Finally, some patients have medical care abroad for the opportunity to travel to exotic locations and vacation in affordable luxurious surroundings.

Booming Medical Tourism Industry

Every year, about 7 million people grab their passports and fly abroad looking for quality, affordable medical care, everything from dental work to weight-loss surgery to cancer treatment. This fuelling an industry worth as much as $40 billion every year. According to WTO data, by 2022 tourism and healthcare will together have become a defining global industry. The total size of the medical tourism market is reached $100bn in 2012 from $78bn in 2010.The reason is because even if you count in the travelers cost to certain destinations, many medical vacations are more affordable than domestic healthcare is in many countries. The global medical tourism market is estimated to grow with a CAGR of 9.5% from 2012 to 2018 owing to lower cost of treatment. Improved quality of care is also one of the essential factors for this shift. Superior infrastructure, better affordability, accessibility and easy availability of information through media, telecommunication and internet access has created huge interest from citizens of developed countries to explore medical tourism as a potential option for treatment of their diseases.

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Global Medical Tourism Market

Global Medical Tourism Share

120 100 80 USD Bn 60 40 20 0 Global Medical Tourism Share

2004 40

2006 60

2010 78

2012 100

Broadly speaking, medical tourism is the act of traveling to obtain medical care. There are three categories of medical tourism: outbound, inbound and intra-bound.

Types of Medical Tourism

Outbound Inbound Intra-bound Refers to patients traveling out of a country. Eg: U.S. patients traveling to other countries to receive medical care Refers to patients coming into a country. Eg: Patients from other countries traveling to the U.S.to receive medical care refers to patients traveling within a country (also referred to as domestic medical tourism) Eg: U.S. patients traveling within the U.S. to receive medical care outside their geographic area, typically to a Center of Excellence in another state/region

By recent estimates, $35Bn in healthcare spending was exported from the US last year; a majority went to regions such as Asia and Latin America. Medical Travelers by Source and Destination Europe Latin Middle America East 4% 1% 1% 10% 5% 13% 12% 8% 26% 1% 2% 2%

To From Africa Asia Europe Latin America Middle East North America Oceania

Asia 95% 93% 39% 1% 32% 45% 99%

North America 6% 33% 87% 58% 27%

Factors Stimulating the Growth of Global Medical Tourism

A number of factors are increasing the attractiveness of medical tourism. Many factor influence patient choice to travel to a particular country for treatment. The main reason is the geographical proximity and 18

cultural. Medical Tourism dates back to the times when wealthy Europeans and Asians would travel within their continent or to other continents to seek health related treatments. But, of late, the trend has been popularized by Americans, Canadians, British and others who travel to far-off countries in search for lowcost high quality health care or for care thats not readily available in their country. The following are the reasons:

1. Incredible Savings: Depending upon the destination country and the cost of the procedure back home, expect to save at least 50%.For example: A cardiac bypass surgery is estimated at well over $100,000 in the US. But in India, at a 5-star type hospital, you can have the same surgery for only$10,000. That's 90% savings even after one have paid for your travel, accommodation and vacation for yourself and a companion. 2. No Wait-Lists: Access to immediate service is what attracts those from countries that have public health care system towards medical tourism. A case at hand is that of a Canadian who suffered from chronic back pain for 16 years and was given medication to deal with it for all those years. Tired of the system and of the worsening pain, she went to India to get her spinal surgery. She now tells everyone how she got her life back by going to India. 3. Excellent Quality : To demonstrate their commitment to quality many international providers choose to be accredited by organizations such as JCI, JCAHO and ISO or by their local accrediting organizations. Read testimonials by medical tourists who vouch for the high quality treatment they have received overseas. 4. World-Class Facilities: International providers offer luxurious accommodation, private spacious rooms, and access to hospitality services 24 x 7. The facilities are immaculate and there are no infections that we so often hear about being present in UK hospitals. 5. Access to Latest Technology: The technology and equipments used by them are the latest and the greatest. Its not uncommon to see surgeons working with billion dollar robotic machines in operating rooms. 6. Surgeon Expertise : Most surgeons catering to international patients have either been educated or have received professional training at top schools in the US, UK or in other countries in Europe. They have colleagues in the US, UK and elsewhere, so it should not come as a surprise if they know your local surgeon at home. 7. Personalized Service: Most medical travelers vouch for the genuine and excellent service that they receive from surgeons, nurses and other medical staff alike. The staff to patient ratio is low making high level of personal care possible. 8. Longer Hospital Stay: One of the advantages of medical travel is you get to stay in the hospital for long without incurring hefty room charges. One can have a longer hospital stay than possible in your local hospital back home under the supervision of your surgeon and physical therapist. 9. Great Convenience: Given the ease of international travel combined with low airfares, your lifechanging surgery is just a flight away. Another convenience that you get does not have to leave the comforts of your home until the surgery is due. One can research all you want on the Internet about hospitals and surgeons, share your medical records online with them, book and plan your itinerary on the web, etc. 10. Travel Opportunities: While the primary motivation for most customers is affordable surgery, the opportunity to visit exotic destinations is an additional draw for some. One can choose to have a relaxing recovery in a resort setting or if the surgeon allows you can even enjoy outdoor tourist attractions. 19

Factors Stimulating the Growth of Global Medical Tourism Affordability Travel Opportunitries Longer Hospital Stay Why Medical Tourism?

Large Uninsured Popoualtion Aging Population

Personalised Services

Better Quality Care

Surgeon Expertise

Great Convenience Access to Latest Technology

Long Waiting Time

Innovative Therapies

Global Medical Tourism Growth Barriers

1. Image Problem: Developing countries are believed to be poor and lacking in quality facilities / physicians which leads to skepticism amongst patients. 2. Legal Issues : The consumer must abide by the medical tourism destinations law in the event of bad outcomes/ complications after treatment. 3. Follow-up Care: Patients face difficulty in getting follow-up treatment in their home country after receiving medical treatment abroad. Improper follow-up care when patients return to their home country is one of the major worries, not only for the patient but also for the insurance companies which have to cover the costs of the treatments after the patient returns home. Moreover, domestic health care providers are often hesitant to take on complicated open cases from unknown providers, especially foreign ones. 4. Cultural and linguistic differences: Lots of entrusting medical care to different locations is about a psychological fear of the unknown. Once in a foreign country, a patient may face the risk of miscommunication because of language barriers or lack of familiarity with a foreign culture. These concerns have already been recognized by providers of health services who are responding with multilingual nurses and physicians Hospitals have started to offer non-medical services such as logistics arrangements and hospitality services. For example, London Bridge Hospital arranges airport pick-up services; Bumrungard Hospital in Thailand features a Starbucks caf and McDonalds facilities; and Asian hospitals also offer link-ups with hotels and bed and breakfasts. Hospital staff in medical tourist destinations is also expected to accommodate to the religious, dietary and cultural needs of the patients. Malaysia, for instance, has developed the Feel At Home Program for tourists coming from West Asia which includes Arabic and Middle Eastern food and music. Medical tourists also have concerns regarding the management of privacy and confidentiality issues in foreign countries. Developing of privacy and confidentiality rules to assure patients that the foreign hospital will treat such information responsibly. 5. International travel: There are also visa and travel formalities that inhibit medical tourism. Entry requirements and visa translate into government-imposed barriers to the international trade of 20

medical services. Many authors agree that this barrier could be overcome by international and regional cooperation. There are examples of countries that have begun to change their visa requirements in order to facilitate travel. India for instance, introduced the medical visa to enable patients who wish to travel to India for medical reasons, to enter Indiaand stay for the duration of their treatment. The new M-visas are valid for a year and are also issued to the patients companions. Likewise, some hospitals such as Bangkoks Bumrungard have an in-house visa extension center so as to facilitate visa extensions for patients. 6. Malpractice liability: Another issue is the difficulty of malpractice law and liability, especially in an international setting. If anything were to go wrong during a procedure abroad, the consumer would have to cope with the host countrys legal system. In some countries, injured patients may have limited recourse through the court system, or may not even have the right to sue at all. Additionally, many health insurances do not cover medical tourism because they are worried about potential law suits associated with bad outcomes and malpractice in a foreign country. International and regional cooperation to harmonize malpractice and liability will be of utmost importance. 7. Non-portability of health insurance: One of the most important barriers to the export of health services, especially medical tourism, has to do with the non-portability of health insurance. Health insurance plans do not cover treatments abroad in most cases; but even when they do, patients must generally bear the full cost of travel and obtain only a small fraction of any cost savings. There are indeed several reasons for this. Difficulties and costs that insurers face when monitoring health care consumption as well as the quality of the treatment abroad. The authors add that a low-cost treatment overseas could prove costly to the insurer if the treatment worsens health problems and the insurer has the obligation to cover the costs of subsequent treatment. However, there are also some remedies. For example, insurance companies could institute the requirement for ex ante objective verification of the need for treatment, as well as an objective verification ex post of the receipt of treatment so as to minimize fraudulent claims. Similarly, to overcome moral-hazard problems due to lower prices of health care abroad, they suggest that insurance companies could offer two different contracts, a standard contract for those seeking health care domestically and a contract with lowerpremium but higher-coinsurance payments for those willing to travel abroad. The lower premium would encourage traveling, while the higher coinsurance fee would prevent overconsumption. Insurance companies should encourage overseas treatments in order to cut their own costs. To realize the full gains from trade, insurance plans must cover not only medical but also travel expenses of obtaining treatment abroad. 8. Other Problems: Low training standards of doctors in medical destination countries and low pay or coverage. Global Medical Tourism Growth Barriers

Image Management Non profitablity of Health Insurance Follow Up Care

Barriers
Malpractice Liability Legal Issues

International Travel

Cultural and Linguistic Differences

21

Medical Tourism Primary Destinations and Service Offerings

The primary destinations for Medical Tourism include countries such as Thailand, India, Singapore, and Malaysia. Below are the top countries for health care travel. In each of these countries, medical tourism services are gaining ground. The number of reliable agents, recovery accommodation and travel support services expands each year. Brazil: Brazil is one of the leading places for plastic surgery with more than 4,500 licensed cosmetic surgeons. The country hosted about 180,000 medical tourists in 2012, making it the sixth most-popular destination. A nose job can be had for about 60% less than the cost of the procedure in the US; there's even plastic surgery available for your pet. Home to the highest per capita number of practicing cosmetic doctors in the world. Brazil attracts tourists not only to Sao Paulo and Rio de Janeiro, but also to smaller cities, including Porto Alegre and Santos. Common procedures, such as tummy tucks, breast augmentations, facelifts and rhinoplasty, run $3,000 to $6,500. Costa Rica: Nearly 15% of international tourists visiting this ecological paradise take advantage of its medical services, mainly cosmetic surgery and dental care. San Jose and its surrounding area are home to hundreds of board-certified doctors, surgeons and dentists. Costa Rica is one of the top five medical tourism destinations for Americans. United States: The US, home to some of the world's top medical specialists, played host to as many as 800,000 international patients seeking help with the most difficult health conditions, according to Patients Beyond Borders. Despite its high prices, the country's world-class care for the hardest-to-treat cases made the US the third-most visited country for medical tourists last year. Hungary: Long known for its mineral springs, lakes, baths and spas, Hungary has more dentists per capita than any other country. They are found not only in Budapest, but also in a small town of 30,000 (Mosonmagyarvr) near the Austrian border, which has 160 dental offices. Many European Union visitors come here for major dental care, including cosmetic oral surgeries, full-mouth restorations and implants. India: As many as 400,000 foreigners travelled to India in 2012 for health treatments, making it the fifth most-visited country for medical tourists. High-difficulty operations such as coronary artery bypass graft surgery can be 90% less expensive in India than in the US. More Americans travel here for cardiac and orthopedic procedures than for all other treatments combined. India offers top private hospitals, especially in the larger cities of Bangalore, Delhi, Chennai and Mumbai. Medical travel to India is growing by 30% a year, thanks to increasing numbers of Americans, Canadians and Europeansespecially those seeking expensive cardiac and orthopedic surgeries. These often cost tens of thousands of dollars less here than in their home countries. Malaysia: With more than a quarter of a million medical travelers each year, Malaysia compares favorably to India, Thailand, and neighboring Singapore in terms of its medical facilities, skill and costs. As well as having special burn treatment centers, Malaysian hospitals have created well-man and well-woman packages that include extensive, low-cost physicals and tests promoting preventive care. A battery of tests, including blood work, bone density scan, chest X-ray and treadmill, usually runs just $340, compared to $2,500 in the U.S. Mexico: Mexico now attracts more than 1 million visiting patients, many of whom are Hispanics from the US. Dental work and weight-loss surgery are popular procedures. Its convenient location is the top draw for most Mexico-bound health travelers. More than 70% of Mexicos U.S. patients reside in California, Texas or Arizona. Patients from San Diego, Los Angeles, Phoenix, Tucson and Brownsville make the two- to sixhour drive across the border to a clinic, stay a couple of nights in a hotel and then return Stateside. Many come each year for checkups, dental cleanings, physicals and other treatments that cost much less than in the U.S. The added benefit, of course, is minimal travel. Singapore: A medical tourism veteran, this tiny Asian nationwith a population of four-and-a-half millionhas a health care system that the World Health Organization ranks as the best in Asia and sixth best in the world. Its no wonder that Singapore attracts many international patients. Singapores specialties cover 22

a broad range, including cardiology and cardiac surgery, gastroenterology, general surgery, hepatology, neurology, oncology, ophthalmology, orthopedics and stem cell therapy. Recent additions include the $300million Biopolis, a seven-building, 2-million-square-foot biotechnology research center that opened in late 2003. The Biopolis includes a stem cell bank, thanks to Singapores liberal laws on using human embryonic cells for research. South Korea: One of the worldss most technologically and scientifically advanced nations. South Korea has earned a reputation for spinal surgeries, cancer screenings and treatments and cosmetic surgeries. Many South Korean hospitals are fully digitized, with electronic health records as the standard. Daegu, in the center of the nation, hosts a well-known herbal medicine market dating to the 17th century. On the southern seacoast, Busan attracts many medical travelers to the local Hanyang University Medical Center for lowcost, comprehensive health screenings. Thailand: An established leader in cosmetic surgery, with an excellent medical infrastructure. Thailand turned the crash of its baht currency in the late 1990s into economic opportunity by attracting patients from nearby Japan, Vietnam, China and South Korea. Eventually, Westerners joined the flow to Bangkok and Phuket, primarily for elective surgeries whose low cost more than makes up for the long flight and other travel expenses. Turkey: Some 110,000 foreigners visited Turkey in 2012 for medical treatment. The country, which has more American-accredited hospitals than any other nation, attracts many foreigners seeking inexpensive eye check-ups and surgery. A major procedure such as spinal fusion can be 60% cheaper than in the US. Medical tourists may be surprised to know that this Eurasian country is home to more JCI-accredited health care facilities than any nation outside the U.S. Health care costs compare extremely well even to those in Asia, and the medical system has plenty of doctors who are Western-trained and fluent in English. The Turkish government enforces strict quality standards in every area of medical technology, facilities and personnel. Dunyagoz, in particular, is a center for ophthalmology. Taiwan: Taiwan's health care facilities adhere to some of the highest standards in the world, which helped it attract 90,000 medical tourists in 2012. Taiwan has 22 health care facilities certified by Joint Commission International - that's only 6 fewer than all of China. Major procedures such as a full facelift can be more than 50% cheaper in Taiwan than in the US. Medical Tourism Destinations in World

23

Number of Joint Commission International (JCI) accredited hospitals/organizations in key Asian countries, 2005 and 2011

Comparison of Major Destinations

Major Destinations Medical Tourists(2012) JCI Accredited Hospitals 39 Range of Costs (% of US cost) 6%-28% Popular Treatment Options

Thailand

12,00,000

Alternative Medicine, Cosmetic Surgery, Dental Care, Gender Realignment, Heart Surgery, Obesity Surgery, Oncology and Orthopedics

Mexico US Singapore

10,00,000 8,00,000 6,10,000

30 25 22

25%-35% -8%-33%

Dental work and weight-loss surgery Organ Transplants, Stem Cell Transplants and other high end procedures Alternative Medicine, Bone marrow Transplant, Cardiac Bypass, Eye Surgery and Hip Replacement

India

4,00,000

21

6%-21%

Brazil Turkey Taiwan

1,80,000 1,10,000 90,000

12 10 19

40%-50% 50%-65% 40%-55% Liver transplants, Joint Replacement Surgery, Bone Marrow Transplants, and Reconstructive and Plastic surgery Cardiovascular Surgery, Cosmetic Surgery, Dental Care, Eye Surgery, General Surgery, Orthopedic and Transplant Surgery

Malaysia

6,71,000

6%-23%

24

South Korea

1,50,000

37

30%-40%

Angioplasty, Heart bypass, Knee replacement, Heart Value replacement.

Costa Rica

60,000

30%-40%

Knee replacement, Heart Value replacement, General Surgery, Angioplasty.

Medical Travel around the World

25

Global Medical Tourism Ecosystem

Medical travelers, intermediaries and provider groups are the primary source of momentum in the market while government and insurers are influencing the industry externally.

26

Impact of the U.S. economic downturn in Medical Tourism

The prolonged U.S. recession has had a significant impact on patients ability to afford medical care19 and, by extension, their use of medical tourism. A 2008 study reported that 22 percent of adults reduced the number of times they visited their physician and 11 percent cut back on the number of prescription drugs they took.20 A later poll found that up to 36 percent of respondents reported putting off needed medical care.21 The number of physician visits in the U.S. has declined from 2006 to 2008 by nearly 70,000 per month. Increasing unemployment has likely contributed to the growing number of uninsured in the U.S. Concurrently, the cost of medical care has not declined in proportion to the decrease in consumers incomes, savings and investments. Patients must either decrease the amount of care they receive or look for more cost-effective alternatives. In addition, transportation costs have risen significantly compared to a year ago; this may be contributing to the decline in U.S. patients traveling for care and the rate at which foreigners are traveling to the U.S. for medical services. Since insurance coverage for medical tourism has not yet been widely adopted, the majority of outbound medical travelers pay out-of-pocket for their expenses. In addition, most medical tourism is limited to elective procedures, not acute illness that requires immediate attention. Therefore, the combination of the economic downturn and elective feature of outbound medical tourism substantially reduced its growth in 2008-2009. It will likely resume sustainable growth in 2010, fueled by increased consumer and employer awareness; increased coverage by health plans; increased acceptance by U.S. providers who participate in care coordination via remote technology; pent-up demand for elective procedures (especially outpatient dental and cosmetic procedures); and increased price and quality information by program operators in receiving countries. Note: Health care reform efforts in the near term will likely contribute to medical tourism's growth, though in the long run, it is difficult to assess given uncertainty about the public option, employer and individual mandates. Recession-adjusted Projection of U.S. Outbound Medical Tourism

REFERENCES www.ncbi.nlm.nih.gov Journal List MedGenMed v.9(4); 2007 www.oecd.org/els/health-systems/48723982.pdf www.imtj.com Home Articles and features 2012 articles www.humanosphere.org/.../outsourcing-health-care-the-global-explosion. grailresearch.com/pdf/.../Rise_of_Medical_Tourism_Summary.pdf www.waset.org/journals/waset/v68/v68-236.pdf www.atlas-webshop.org ... Medical tourism: a global analysis www.eclac.cl/.../xml/7/.../Medical_Tourism_A_Survey_L111_final.pdf digitalscholarship.unlv.edu/cgi/viewcontent.cgi?article=2484&contextwww.medicaltourismassociati on.com/en/medicaltourismconference.html internationalliving.com/2010/06/the-top-10-medical-travel-destinations 27

www.global-medical-facilitators.com/#!medical-tourism-destinations/c8k2 articles.economictimes.indiatimes.com Collections Health Care http://www.kenresearch.com/travels-and-tourism-industry-analysis/tourism-industry/India-MedicalTourism-Industry/236-98.html OIFC : Tourism in India: Key Potential and Investment Opportunities http://www.ijbmi.org/papers/Vol(2)1/Version_3/C212129.pdf http://articles.economictimes.indiatimes.com/2013-06-27/news/40233610_1_medical-touristsweight-loss-surgery-health-care http://www.bloomberg.com/slideshow/2013-06-25/top-travel-destinations-for-medical-tourism.html articles.economictimes.indiatimes.com Collections www.mtqua.org/.../top-10-worlds-best-hospitals-for-medical-tourists-ne..

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CHAPTER-3 MEDICAL TOURISM IN DEVELOPING ASIAN COUNTRIES

Medical tourism or medical travel is a rapidly growing industry catering to patients who travel across national borders to receive medical treatments. In Asia, medical tourism has emerged as one of the fastest growing segments. Low cost and waiting time of medical treatments as compared to western countries, coupled with quality health services provided in Asian countries make them preferred destination for the medical travelers. With the governments' support and improving medical infrastructure of Asian countries, the medical tourism market of Asia is anticipated to post a CAGR of around 26.5% during 2013 to 2015, say the authors in their latest report Asian Medical Tourism Market Forecast to 2015. The Asian medical tourism market comprises India, Thailand, Malaysia, Taiwan, Singapore, and Korea. As per this study, the authors found that among the medical tourism destinations, these six Asian countries are expected to be the most potential destinations in the coming years. Extensive research and analysis revealed that cost competitiveness is one of the major factors responsible for making Asian countries a preferred destination for medical tourists. The cost of medical treatments in developed countries, particularly in the US and the UK, has been significantly high, which has prompted the patients from these regions to visit cost effective destinations. It has also been observed that alternative traditional treatments like ayurveda, naturopathy, aromatherapy, homeopathy, meditation and yoga are becoming popular among the medical tourists. Many tourists come to Asian countries to seek the divine peace and healing power provided by these alternative medical therapies. Major Treatments under Medical Tourism From marketing materials it is apparent that the range of treatments available overseas for prospective medical tourists are wide, including: Cosmetic surgery (breast, face, liposuction) Dentistry (cosmetic and reconstruction) Cardiology/cardiac surgery (by-pass, valve replacement) Orthopedic surgery (hip replacement, resurfacing, knee replacement, joint surgery) Bariatric surgery (gastric by-pass, gastric banding) Fertility/reproductive system (IVF, gender reassignment) Organ, cell and tissue transplantation (organ transplantation; stem cell) Eye surgery Diagnostics and check-ups.

Cosmetic Surgery Eye Surgery Dentistry

Organ, cell and tissue transplantati on

Various Treatments under Medical Tourism

Cardiology/ Cardiac surgery

Fertility/ Reproductiv e System

Orthopaedic Surgery Bariatric Surgery

29

Asian countries amongst top ten Medical Tourism Destination

The Asian medical tourism market comprises India, Thailand, Malaysia, Taiwan, Singapore, and Korea and these six Asian countries are expected to be the most potential destinations in the coming years. This is not just because they provide sophisticated tourism infrastructures and excellent healthcare facilities, but also for the following more precise reasons:

India The India health care system is popular because of the high-quality care given in world-class facilities by expert doctors using the latest technology at remarkably low cost that covers almost everything. It should be said that cardiology is a specialty in India, and other complex procedures too, like ones in the areas of neurology and oncology. For example, the Artemis Health Institute, which is possibly Indias best hospital, has a partnership agreement with the finest cancer center in the world, New York City-based Memorial Sloan-Kettering. South Korea The South Korean Health Ministry has set a goal of up to 300,000 medical tourists by 2015. Many tourists from western countries are heading there for things like cancer treatment, organ transplantation, joint/rheumatism care, and Korean traditional medicine. The most popular treatments for medical tourists are cosmetic procedures such as eyelid surgery, nose jobs, facelifts, and skin lightening and these are very popular in korea. Malaysia In 2013, Malaysia was expecting nearly 600,000 medical tourists. Part of its appeal is due its citizens high English-language proficiency, which includes many healthcare professionals from doctors to nurses to technicians to the doorman at one of their modern hospitals. Plus, theyre developing a campaign to announce Malaysia is my second home which focuses on building planned communities which include healthcare facilities for retired people from the US. Singapore The World Health Organization ranks their healthcare system as 6th best in the world; that nearly 1 million medical tourists were drawn there in 2012 by short wait times, expert doctors, and a dozen JCI accredited hospitals; and in addition to this over one-third of Singaporeans speak English language.

Taiwan Taiwan is known for liver transplants, joint replacement surgery, bone marrow transplants, and reconstructive and plastic surgery and has made a concerted effort to gain a large share of the Canadian market where long wait-times for certain treatments is a common problem and flights heading North over the Arctic make it a fairly convenient option.

Thailand Thailand is Asias oldest player in the medical tourism sector. It offers good healthcare infrastructure, and provides world-class private healthcare facilities bestowing cost-effective medical treatments utilizing skilled and qualified medical staff, well-trained doctors, and specialists for cosmetic surgery, anti aging treatments, infertility procedures and health spas.

30

The various treatments offered by these countries are: Country Singapore Malaysia Thailand Medical Treatment Offered Cancer treatment, Stem Cell treatments and organ transplant Dental, Cardiac Surgery, Orthopedic, Transplant Surgery and Cosmetic Plastic Surgery Alternative Medicine, Cosmetic Surgery, Dental Care, Gender Realignment, Heart Surgery, Obesity Surgery, Oncology and Orthopedics Cardiology, Neurology, Oncology Liver transplants, Joint Replacement Surgery, Bone Marrow Transplants, and Reconstructive and Plastic surgery

India Taiwan

Top seven Medical Tourism Hospitals in Asia

Out of major hospitals in the world for medical tourism, seven are located in Asian continents that provide world-class medical facilities for the medical tourists. Hospital Prince Court Medical Center Fortis Hospital Wooridul Spine Hospital Bumrungrad Hospital Bangkok Hospital Medical Center Gleneagles Hospital Asia Heart Institute Country Kuala Lumpur, Malaysia Bangalore, India Seoul, South Korea Bangkok, Thailand Bangkok Thailand Singapore Mumbai, India

1. Prince Court Medical Center Kuala Lumpur, Malaysia An internationally-accredited, multi-specialty hospital that features a high-tech burn unit, an In Vitro Fertilization department, and an international patient coordination team that ensures medical tourists needs are met. PCMCs honor marks the first time a Malaysian hospital has taken the top spot. 2. Fortis Hospital Bangalore, India This hospital provides services in nearly 40 specialties like cardiology, orthopedics, and neurology, and played an integral role in introducing High Intensity Focused Ultrasound (HIFU) technology to the worlds cancer treatment options. 31

3. Wooridul Spine Hospital Seoul, South Korea This was the only hospital to make the list that concentrates on one specific area of medicine, as orthopedic care has become one of South Koreas many specialties. In a recent article highlighting the facilitys expertise, the hospitals president was quoted as saying Were a one -stop service. We have everything an international patient needs. 4. Bumrungrad Hospital Bangkok, Thailand The first of Thailands two entries may well be the most famous hospital for medical tourists, if not the longest-serving. Bumrungrad has welcomed international patients with regularity for over 20 years and have earned a reputation for not only delivering quality care, but being organized and efficient for people on healthcare holiday. 5. Bangkok Hospital Medical Center Bangkok Thailand The second example of the excellent Thailand medical tourism system, Bangkok Hospital Medical Center is the crown jewel in a chain of private hospitals that includes the esteemed Bangkok Heart Hospital, Bangkok International Hospital, and Wattanosoth Cancer Hospital, and their website offers a Fast Track service for arriving and departing international visitors. 6. Gleneagles Hospital Singapore The modern city-states lone representative on the list is Gleneagles Hospital whose medical specialties include bladeless femtosecond laser cataract surgery and oncoplastic breast conservation surgery. 7. Asia Heart Institute Mumbai, India Finishing the list of top hospitals for medical tourism is this world leader in cardiology which has achieved the lowest mortality rates in the world in isolated bypass surgery.

Medical Tourism in South East Asia

Medical tourism is a billion dollar industry in Southeast Asia and countries like Singapore, Thailand and Malaysia are growing the share of the market by offering state-of-the-art medical services at affordable prices. "A US$ 3 billion business comes from Thailand, Malaysia and Singapore alone. Thailand specializes in sex changes, Singapore in joint replacements and liver transplants, Malaysia in cardiac surgery. "The private sectors in Singapore, Thailand and Malaysia have capitalized on their comparative advantage to promote medical tourism, combining health services for wealthy foreigners with travel packages to boost consumption of such health services. Patients from elsewhere, including the developed countries, are choosing to travel for medical treatment, which is perceived to be of high quality or value for money." Number of Medical Tourist visited in Singapore, Malaysia and Thailand in 2012:

No. of Medical Tourist Visited in 2012

1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 1400000

610000

671000

Thailand

Singapore

Malaysia

32

Revenue Generated in millions US Doallars (2012)

4000 3500 3000 2500 2000 1500 1000 500 0 Thailand Singapore Malaysia 800 570 3500

Singapore: The beautiful island city-state of Singapore has seen a boom in medical tourism over the years. Many people club their Singapore holiday with healthcare. In 2011 alone, tourism receipts from foreigners travelling for health care in Singapore stood at over $900 million. Singapore has one of the most sophisticated health care systems in the world, especially for cancer treatment. As many as 610,000 medical tourists visited the country in 2012, mostly from Indonesia. That makes the country the fourth-most visited place for medical tourists. Singapore has 22 facilities certified by Joint Commission International, the U.S.-based quality and safety accrediting organization. That's 14 more than all of neighboring Malaysia. The popularity of Singapore medical tourism can be attributed to a couple of factors. One of these is the presence of a robust medical infrastructure and a world-class airport. An integrated Singapore healthcare system is yet another reason why it has witnessed a huge influx of foreign medical tourists. In fact, Singapore comes in 6th on WHOs list of the 191 countries with the best health systems. Even as Asia is buzzing as a medical tourism destination and there is a competition amongst countries in the continent, people from across the world continue to travel to Singapore in droves for high-quality and affordable treatments. The top treatments sought in Singapore are liver transplant, kidney transplant and those associated with blood disorders. Why Medical Tourism in Singapore Singapore is one of the most developed countries in Asia. It has become a top healthcare destination. Healthcare in Singapore is one of the best in Asia. The country specializes in every major treatment available. In 2011, Singapore medical tourism attracted 30% of the people who went abroad for medical tourism. Medical tourists choose Singapore healthcare for a variety of reasons. Some of them are mentioned below: 1. Safe, trustworthy and excellent patient services Many Singapore hospitals have been accredited by international accreditation agencies like the JCI. Doctors in Singapore have received training from renowned centers around the world. Healthcare institutions in Singapore publish clinical outcomes on their website and these are comparable to, if not better, in quality than those of other counties. By clinical outcomes we mean the measures that are taken to track the clinical services quality.

33

2. Regional hub for medicine Singapore is not only a regional hub for the best medical practices, but also a place where medical professionals meet for training, seminars and conferences. Singapore is also a healthcare consultancy base. Many biomedical companies have set up regional headquarters in Singapore. 3. Affordability Although healthcare costs in Singapore are more expensive than in other Asian countries that specialize in medical tourism, its still affordable and cheaper than treatment costs in the western countries like US and UK. In Singapore you will find the same quality of treatment that you will find in other developed countries. 4. Singapore is a highly developed country Singapore is an urbanized country. It is one of the most developed, clean and efficiently managed countries in Asia. It is a leading financial center and one of the world's busiest ports. Singapore has one of the highest life expectancy rates in the world and nearly everyone has access to clean water and sanitation facilities. 5. Well developed biotechnology industry Singapore has invested in its biotechnology sector. If you are suffering from an illness that requires specialized treatments like stem cell therapy, Singapore is probably one of the best options. In Singapore you will also have access to cutting edge cancer treatments. 6. Feels like home Singapore is connected to all the major cities of the world. People of all cultures have made Singapore their home. The country is multicultural and multiracial and accommodates people from everywhere. English is widely spoken. In Singapore tourism is well developed and the city is widely connected with metro-rails, cabs, and buses for efficient transport. 7. Peace of mind In Singapore you can be assured that you will receive the best medical care. The county is very safe for tourists and there is no danger of any riots, social or government unrest. You can focus on recovering and not worry about anything else. 8. The climate Singapore is very close to the equator and as a result has a tropical climate. The weather is warm and congenial throughout the year. Singapore has a tropical rainforest climate and as such there are no seasons. The temperate is always uniform with abundant rainfall. Health care System and Quality in Singapore The health care services in Singapore extend to both private and public health care. These services are complemented by improving the standards of housing, living, medical services, education and preventive medicine. The government ensures that affordable and good basic medical services are available to all its citizens. The health care system is constantly fine-tuned to ensure it is aligned with the philosophy of accessibility for all residents of Singapore. Hospitals and Doctors Standards in Singapore The hospital standards in Singapore are quite high and multi-disciplinary services are provided for both inpatients and outpatients. Accident and emergency services work 24 hours a day and there are numerous specialist centers as well. All health care providers like doctors, pharmacists, dentists and nurses are all registered with Singapore's Medical Council, Singapore Pharmacy Board, Singapore Dental Council and Singapore Nursing Board respectively. Although it may not be well known Singapore has one of the world's finest health care systems. It is also known for efficiently financing and yielding results for the local community. The medical standards of Singapore are amongst Asia's highest. The doctors are well qualified and pharmaceuticals are sold in various outlets including department stores, shopping centers, hotels and supermarkets. Hotels usually provide doctors on call 24 hours a day. In case you need to be shifted to a hospital, quick and efficient transport such as an ambulance is usually organized. Singapore is one of the medical hub in Asia not just for patients but even for professionals. Conferences and training are held here making it a great site for innovation in health care services. 34

Singapore Visa Requirements for Medical Tourists For most Westerners traveling to Singapore a visa is not required. British and Irish visitors receive a 30-day stamp upon arrival, but must show proof of an onward ticket. Foreigners seeking medical treatment in Singapore may apply for an extension via the online e -EXTEND program. This allows a one-time only extension for up to 89 days from the date of entry, and applies only to those who havent previously obtained an extension of stay on their current trip. In order to obtain the extension, your Visit Pass must have a remaining validity of not less than 2 days, excluding Sundays and public holiday, and you may not return to Singapore within 5 days of the departure date of your current trip. As for ASEAN visitors, Singapore provides free entry to the citizens of those countries, and, certain restrictions apply to visitors from a handful of Middle Eastern countries who may require a local sponsor, which would likely be provided by their doctor there.

Thailand
Thailand, along with its Asian neighbors Singapore and India, accounts for 90% of Asias medical tourism market. Each year, over a million foreigners plan their medical travel around a Thailand holiday clubbing sight-seeing with medical treatments. On the tourism front, Thailand has been a popular destination for decades. In the past few years, Thailand has gained a reputation as a high-quality and reliable medical tourism destination. In no small part, Thailand owes it to the hospitality of the Thai people. Thailand has earned the eponym of the 'Land of Smiles'. The Thais treat their guests with the utmost respect and try to serve them the best way they can. On another hand, Thailand medical tourism has seen its popularity rise owing to the fact that it is home to many internationally accredited hospitals. These hospitals offer a gamut of treatments, right from cosmetic/plastic surgery and dental tourism to organ transplants at affordable rates. Some procedures will cost you 1/10th of the price it would take for similar medical procedures in the US, UK or Australia. Hospitals here boast the latest technology, and are equipped with language translators and exclusive international wings to cater to foreign patients. Many doctors and physicians in Thailand have medical certifications from the UK and US, and attend to patients with consummate professionalism and great care. Why Medical Tourism in Thailand Thailand is not only a major tourism destination in the world but also one of the most popular countries for medical tourism. More than a million foreigners travel to Thailand every year to get medical and surgical procedures done. In 2010, the number of international patients getting treated in Thailand was about 1.8 million people and the number is constantly growing annually.

1. Affordability The cost of medical treatment in Thailand is one of the lowest in the world. The huge savings and the fantastic quality of Thailand medical facilities draw many medical tourists to Thailand. Indeed, the medical facilities in Thailand are some of the best in the world. All the latest equipment and facilities for treating even the most difficult illnesses can be availed off in Thailand for an affordable cost. For example, a heart bypass surgery can cost upwards of $144,000 in the US, but the same operation will cost around $26,000 in Thailand. 2. World Class and International Accredited Medical facilities Many private hospitals in Thailand are Joint Commission International (JCI) accredited. On last count there were 35 of these (as of September 2012). Many more are ISO certified and are in the process of getting a JCI accreditation. Over 350 hospitals have a hospital accreditation from the Ministry of Public Health. All the latest technologies and facilities are available in the largest private hospitals.

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3. Highly trained and experienced doctors, nurses and paramedical staff Thailand has a pool of highly trained doctors many of whom have studied/practiced abroad. With this international experience they are able to offer the latest and safest medical procedures. They will perform a wide range of surgeries like plastic surgeries, cardio thoracic surgeries, pediatric surgery, and neurological surgery, dental implants, LASIK, etc. Nearly all of the doctors and most of the nurses speak English. Translator services are also available should you require them. 4. Excellent Service Thailand is famous for its hospitable treatment of visitors. The people are a friendly lot and hospitable service to guests is engrained in the culture. You will be surprised to see how far the Thais will go to make their guests comfortable. 5. Holistic and Alternative treatments There are many medical spas and wellness centers in Thailand offering alternative treatments like Thai massages, Thai foot massages, aromatherapy massages, and Thai therapeutic massages. Many of these therapies are exclusively found only in Thailand. Apart from this, Ayurveda and Traditional Chinese Medicine (TCM) is also widely known and can be easily found in Thailand. 6. Better bundling of services Patients going to other Asian counties mostly focus on specialized treatments. But the major Thailand hospitals offer full fledged services under one roof. One major private hospital in Thailand treats 1.2 million patients annually and offers more than 34 specialties. Thailand offers a range of services that even the most demanding foreign medical tourist will find comforting. The vast number of patients that the doctors work on has ensured that they have vast experience, the hospitals are better equipped and the prices are kept low due to economies of scale. 7. Fewer entry procedures The procedures in Thailand are less cumbersome than many other countries in Asia. Foreigners who travel to Thailand must have a passport that is valid for the next 6 months. Travelers from over 41 countries can stay in Thailand for up to 30 days without a visa. This is also called Visa Exemption. If you are traveling into Thailand overland, you can get in for 15 days without a Visa. These include countries like the United States, United Kingdom, Germany, Australia, Hong Kong and many others. Travelers from 21 other countries can apply for a visa upon arrival. 8. Tourist destinations where you can relax and recuperate Thailand tourism offers diverse attractions, great tourism infrastructure, delicious Thai food and friendly people. The country has many tourist places and is one of the top draws for tourists from all over the world. Thailand is a beautiful country and the tourist places contrast from hill resorts and sun kissed beaches to exotic islands. Thailand is an aviation hub; all major international airlines run flights into Bangkok and elsewhere every day. You can choose from many first class hotels where accommodation and food boasts international standards. Healthcare System and Quality in Thailand Thailand is a much sought after healthcare destination. More than a million healthcare tourists visit Thailand every year to avail healthcare services owing to its excellent medical and health care quality. Healthcare in Thailand is provided by government hospitals, private hospitals, non-governmental organizations and private practitioners. A World Bank featured story titled, 'Thailand: Sustaining health Protection for All' says 99.5 % of the Thai people have access to healthcare under schemes promoted by the government. The budget allocation to healthcare is high and it is increasing steadily. Citizens are covered under schemes such as the Universal Coverage Scheme, Civil Servant Medical Benefit Scheme, Voluntary Healthcare Card Scheme, etc. The Ministry of Public Health controls most of the hospitals in Thailand. There are more than a thousand government hospitals in the country. Government hospitals in Thailand are of three types, there are regional hospitals in the provinces with at least 500 beds, general hospitals in major districts or province capitals with 36

a capacity of 200 to 500 beds, and community hospitals in the districts that can admit 10 to 30 patients. The community hospitals provide basic medical care and refer the more advanced cases to the general hospitals or the regional hospitals. The quality of healthcare in the government hospitals is generally good; however, as the hospitals cater to a large number of people, you can expect a long wait. Foreigners have to pay normal charges and the benefit of the government schemes is not available to them. The advantage is government hospitals offer low cost healthcare compared to costs levied by private hospitals. In all probability, you will be admitted to a general ward unless you are willing to pay extra for a room. The private hospitals are the best equipped and of these there are more than 300 in various parts of Thailand. You will find many of them in Bangkok and popular tourist destinations, while other major provinces will have at least one private hospital. Specialist clinics such as dermatology clinics, cosmetic plastic surgery clinics as well as medical and wellness spas are widely available throughout the country. Hospitals and Doctors Standards in Thailand Hospitals and medical facilities in Thailand pride themselves on their high standards, and many have subjected their premises and systems to the most rigorous classification by applying for international accreditation and certification. Thailand was the first country in Asia to achieve JCI accreditation in 2002, and 39 hospitals are now accredited (data as of August 2013). Many more healthcare providers are ISO14000 and ISO9000 certified. Though the ISO certification is not a hospital accreditation, these standards of general management and environmental management is a sign of quality assurance in healthcare that indicates the hospitals commitment to deliver sustainable, high -quality facilities and services. Additionally, more than 350 Thai hospitals have acquired Hospital Accreditation (HA), awarded by the Ministry of Public Health. International patients in Thailand will find that English-speaking general practitioners, dentists and surgeons are generally available in private hospitals and specialist clinics. Moreover, many hospitals offer translator services in most possible languages from Russian and Arabic to Dutch and Japanese. Many Thai doctors and surgeons practicing in the private sectors today have won awards for their work and endeavors and many specialist doctors have earned international qualifications from western countries such as the US and UK. That being said, more than 500 doctors practicing in Thai hospitals and clinics nowadays are American Board Certified. Thailand Visa Requirements for Medical Tourists Visa on arrival is typically 15-30 days (most visitors from Western countries receive 30 days) and Visa extensions can be applied if necessary. Tourists can also apply for a non-immigrant Visa for medical reasons, which gives them 90 days and requires proof that theyre receiving treatment from a licensed medical facility. In addition, starting from early 2013, medical tourists from GCC countries including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and The United Arab Emirates can enter Thailand for 90 days without visa. Please note that you cannot enter Thailand for medical reasons under Visa exemption rule. The Visa must be obtained before leaving your homeland. However, it is not a problem to stay in Thailand as a tourist after treatment, provided the validity on the Visa still remains.

Malaysia
Malaysia is a beautiful country located in South-east Asia. Malaysia tourism is one of the main sources of revenue in this country. Going on a Malaysia holiday is sure to leave you with many memories for a lifetime. On a travel to Malaysia, you can experience a perfect mix of luxury and natural beauty. While the Malaysian capital city of Kuala Lumpur is filled with shopping malls and high-rise buildings, the nearby countryside will amaze you with its wide-open fields and gorgeous tropical environment. This country, which is thronged by millions of tourists every year, is also a forerunner in the field of medical tourism. 37

The rapid growth of Malaysia medical tourism can be attributed to the presence of hospitals using highly sophisticated technologies and comparatively lower cost of Malaysia healthcare. The health care centers in Malaysia also have a large number of highly skilled medical professionals. Malaysia medical tourism is regulated by the Ministry of Health Malaysia, ensuring the quality of medical providers to medical tourists. The promotion of medical tourism of the country is carried out through Malaysia Healthcare Travel Council (MHTC).Malaysia Healthcare Travel Council (MHTC) chief executive Dr Mary Wong has said the number of medical tourists jumped from 392,000 in 2010 to 671,000 in 2012. The council expects to receive 700,000 medical visitors this year. Data from the council has shown the market growing in revenue from RM511 million in 2011 to RM594 million last year.

No. of Medical Tourists in Malaysia

800,000 700,000 600,000 500,000 400,000 No. of Medical Tourists 300,000 200,000 100,000 0

2010

2012

F 2013

Why Medical Tourism in Malaysia The rise in popularity of Malaysia as a medical tourism destination can be attributed to many factors, some of which are mentioned below: 1. Excellent medical services at unbelievably low prices Malaysia is a health care destination mostly visited by US and UK patients. The rising cost of health care in these countries is attracting more and more visitors to Malaysia. The exchange rate of currency in Malaysia is low, which attracts a large number of westerners to the place. 2. State-of-the art health care facilities The health care in Malaysia is quite advanced, thus making the country one of the top 5 medical tourism destinations in the world. The country has a wide network of clinics and hospitals which have state-of-the art facilities and most modern infrastructure. These hospitals provide a large variety of procedures and medical services which include dental, cardiac surgery, and cosmetic plastic surgery, at unbelievably low prices. People coming in for cosmetic surgery can also choose the package of their choice which includes luxury accommodations or recuperating after the surgery. The country has also shown a high success rate in fertility treatments. Malaysia medical tourism gives you the opportunity to go for many holistic services like Unani, Ayurveda, and traditional Chinese medicine offered by the country. These alternative treatments are proven to cure the illness, compliment the general treatments, and also increase the bodys resistance. 3. Presence of highly qualified professionals Most of the medical professionals in Malaysia hospitals have received their certifications from abroad. This international exposure enables them to relate with patients from different cultures and also helps them to offer the safest and latest medical practices. In Malaysia, patients do not have to visit many hospitals for various treatments. This is because most of the hospitals in the country provide a large number of facilities under one roof itself. 38

4. No language barrier Malaysia is a multicultural country with English being a language thats widely spoken among its residents. Speaking English is a norm in the Malaysian medical community. The hospitals also have international patient help centers and translators for the aid of foreign medical tourists who are visiting them. 5. Provides quick service At the hospitals in Malaysia, you can get treatment without having to face a long waiting list. The patients may get hospitalized on their arrival and the remaining tests and examinations are also done in a prompt manner. The efficient and organized patient registration systems help in reducing long patient queues. The treatments and medicines are dispensed to patients as quickly as possible so that they can decide whether to return home or to recuperate at a location of their choice. 6. Excellent recuperation facilities Malaysia healthcare centers, which are a part of the medical tourism program, also arrange for postprocedure aftercare facilities at highly impressive places. The patients can also relax at the hospital rooms or at nearby places, where the medical practitioners can keep a close watch on them. 7. A peaceful environment The surroundings outside the Malaysian medical facilities also act as a high impetus for attracting health tourists. The country is quite peaceful and is free from threats of any sorts. The crime rate in Malaysia is also extremely low, which serves as another attraction for tourists around the world. The people of Malaysia are very welcoming and hospitable. The country has a high social and economic stability and the literacy rate over there is very high. The scenic beauty, amazing food, and friendly residents also distinguish Malaysia from other medical tourism destinations in Asia and around the world. 8. A tourist paradise Malaysia offers its visitors a large number of exotic locations. So, if you are in Malaysia for medical treatment, you can also take some time to roam around the place. In addition to the innumerable number of malls, shopping destinations, and historic buildings, you can get to see beautiful beaches, lush green forests, and mountains, on a travel to Malaysia. 9. Easy to travel Traveling to Malaysia is also quite easy as the capital city of Kuala Lumpur is well-connected by air, to all other major destinations in the world. Getting from one city to the other is also quite easy as they are very well connected by public and private modes of transportation. The procedures of traveling to the country are very easy when compared to many other countries in Asia. 10. Visa benefits for medical tourists Travelers from Western countries will get a 3 months Visa once they come to Malaysia and hence they neednt apply for Visa beforehand. With a letter from the medical centre where you are receiving treatment, you will be able to obtain a visa extension for up to 6 months. Healthcare System and Quality in Malaysia There are many hospitals in Malaysia that are accredited at an international level by the JCI (Joint Commission International). The Malaysian Society for Quality in Health (MSQH) also issues accreditation on a national level to the hospitals to ensure the maintenance of quality in health care. The Ministry of health in Malaysia works with various healthcare services to ensure that medical and health care quality is not compromised. According to the rules of quality assurance in health care, all healthcare providers are supposed to be licensed under the Health Care Facilities Act of 1998. The association of private hospitals in Malaysia also strives to bring about the quality required in health care. Many of the hospitals in the country have both national and international accreditation.

The Malaysian government is also taking huge steps to promote medical tourism in the country. The Malaysia Healthcare Travel Council (MHTC) has been set up to promote and position Malaysia as the premier healthcare destination in the region. Under the current tourism development program, 35 private hospitals in Malaysia have been chosen to promote medical tourism. The Malaysian Ministry of Health has also launched a website to support the mission, and they are considering including wellness centers, in addition to hospitals, in their medical tourism offerings.

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Malaysia Visa Requirements for Medical Tourists As with many countries, Malaysia has many different criteria pertaining to passports and visas, depending on where you are from. While most visitors do not require a visa to enter Malaysia for short stays, the citizens of some countries do. Also, some are required to obtain visas depending on the duration of their stay, whether that is for 14 days, one month, or 3 months and longer. There is no special visa for med tourists, so you would be a regular tourist when receiving your care there.

Philippines
Philippines is a beautiful country and also a favorite destination for tourists around the world. This country, which constitutes 7101 islands, is blessed with beautiful coral reefs, beaches, mountain ranges, and tropical rain forests. Visitors can also enjoy the luxuries of city life in places like Metro Manila and Cebu City. Philippines is also a major destination for global health tourists.

On a travel to Philippines, one can enjoy the best of health care services while indulging in the natural beauty of the islands. The fast paced growth of Philippines medical tourism can be attributed to the presence of good facilities and treatment procedures that are safe. Medical tourists can also enjoy a rejuvenating treatment at world-class spas over here. Highly qualified professionals and affordable as well as effective treatment procedures are the key features of health care in Philippines. The friendly and hospitable natives of Philippines will make your stay in this island country a memorable one. Why Medical Tourism in Philippines The world class medical facility available in Philippines has made it a popular choice for medical tourists around the globe. The reasons for the growing popularity of Philippines as a tourist destination are given below: 1. A low-cost medical treatments In Philippines, one can get medical treatments at surprisingly low costs. Apart from the surgical procedures, the medications which are required during the recovery process also cost less in this country. The living cost in Philippines is also very low when compared to foreign countries. So, even if the accommodation and transportation costs are added, the total treatment cost for visitors will be very much lower than their home country. One can choose from the many health care packages, which includes travel, accommodation, and hospital services. For getting best facilities, you will have to find the right hospitals to provide the exact services that you require. 2. Quick and remarkable service provided by hospitals In a Philippines medical center, one neednt face the long waiting queues and insurance hassles in order to get treatment. The hospitals are also equipped with the latest tools and medical facilities. Due to all these reasons, more and more international tourists are visiting this island nation for enjoying their holiday and getting medical treatment as well. 3. Hospitals of international standards Philippines medical tourism offers the services of many super specialty clinics and over 2000 hospitals. The capital city of Manila, which also contains many popular tourist spots, is considered to be the hub of medical tourism in Philippines. The city boasts medical schools of international standards and hospitals with admirable infrastructure. The private rooms in these hospitals have facilities that are at par with five star hotel rooms. 4. Highly qualified staff The staff in these hospitals is highly skilled and the facilities offered are at par with the standards that are available in developed countries. Most of the medical staff has international exposure, being trained and having worked in places like US, Australia, and UK. They are also updated on the latest advancements in the field of medical science. Most of the doctors spend almost 2 months a year in the US, for advanced studies so as to be fully updated with the latest developments in their field of work. The medical staff over here is extremely courteous, hospitable, and always at your service, thus making your treatment phase a relaxed and tension-free one. 5. Easy to travel Traveling to Philippines is quite easy as its capital city is well connected to almost all the major airports in the world. The US and Canadian visitors to Philippines are permitted to stay up to 21 days upon arrival. Those who wish to stay for a longer period should obtain a visa before they leave their native country. 40

6. No language hassles Foreign tourists in Philippines will not have any trouble in getting around as English is spoken by almost 90 percent of the population here. Hospital rules dictate that all communication should be carried out in English. The medical staff can easily explain to their patients all they know regarding the medications to be taken and the precautions that should be followed after the treatment. This reduces the chances of misunderstanding which can occur between a foreign patient and a doctor. Moreover, the health care centers in Philippines have help desks and translators at your service, round the clock. 7. Variety of medical services offered Philippines medical tourism offers services like hip and knee replacements, spine treatment, dental services, cardiac care, infertility treatments, cancer therapy, weight loss treatments, and many other procedures. Dental services are one of the most sought-after treatments in the country as they offer dental surgery, dental implant treatments, prosthetic dentistry, and cosmetic dentistry. There are also many health travelers who opt for cosmetic surgery procedures like face lifts, thread lifts, and laser surgeries. 8. Patient-friendly locale Tourists who undergo treatment in Philippines have the option of recuperating at any of the islands in the country. The islands provide a stress-free environment and also allow for proper after-care and follow-up treatments. You can treat yourself at many spa resorts and can experience a quick and enjoyable recovery. The relaxation centers and natural health spas offer packages that include organic diets, detoxification processes, massages, and meditation. The geographical proximity of Philippines to countries like Taiwan, Japan, Australia, and South Korea, which have highly expensive medical services, is another reason behind the huge success of Philippines medical tourism. Healthcare System and Quality in Philippines The medical tourism program in Philippines, which was launched in 2006, can be considered to be a huge success. The hospitals in Philippines also have international accreditation offered by the leading British company, QHA Trent. The Joint Commission International (JCI), an American accreditation group has also accredited the major hospitals in the country. The government of Philippines is rolling out many plans to boost the medical tourism infrastructure and to enhance the standards of healthcare providers in the country. Along with this, well-planned international marketing campaign is being carried out to highlight the position of Philippines in the list of the top medical tourism destinations in the world. However, there is a stark difference in the healthcare services and facilities provided at private and public institutions. It is recommended that the visitors take advantage of the medical tourism facilities offered by private organizations, if they want to get the best treatment.

Indonesia
Indonesia is facing a large scale problem with their healthcare care industry, which could cost the nation up to $50 billion to get the infrastructure up to standards by 2020. The problems with the Indonesian healthcare sector are many, not enough supplies, disparity between rich and poor and often discrimination against the poor and not enough government money to initiate growth. The government is aware of the problems and is trying to develop a creative way to fix them, the medical tourism and pharmaceutical market reform may be the proper tools to do it. The lack of necessary medical equipment, supplies, doctors, and beds is one of the main concerns with the Indonesian healthcare industry. There is one hospital bed per 1,000 people in Indonesia, well below the world average of 3.6 per 1000 people. There are also only 25 doctors per 100,000 people. Indonesian hospitals are also full of antiquated and obsolete equipment. These problems place the healthcare rating of Indonesia at the bottom of its ASEAN (Association of Southeast Asian Nations) peers. The issues plaguing the Indonesian healthcare market cause the rich Indonesians to spend as much as $600 million to travel to Singapore, Malaysia, and Australia for their medical treatment. 69 percent of all medical tourists in Malaysia are from Indonesia, according to Rhenu Bhuller, vice-president of healthcare for Frost & Sullivan Asia Pacific. This causes quite a disparity between the rich and the poor, the rich leave to receive healthcare, and their money does not stay in the local healthcare industry so it stays downtrodden and poor, and only the poor to average income people of Indonesia go to these failing 41

hospitals. On some occasions, the hospitals turn away people who cannot afford to pay. According to the Jakarta Legal Aid Institute (LBH), this was the case for Rusdin Zakaria. Rusdin was complaining about shortness of breath and was taken to the ICU of Prikeasih Hospital in South Jakarta, where he was charged 7 million rupiah ($800) down payment which he and his family could not afford. He was transferred to Fatmawati General Hospital, which would charge them less; he died before reaching the second hospital. Nurkholis Hidayat, the director of LBH reported the family was afraid to report the incident to the media, for fear of further discrimination. Cost Comparison between Thailand, Malaysia and India (Data in comparison to USA) S.no 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Treatment Heart Bypass Angioplasty Heart Valve Replacement Hip Replacement Hip Resurfacing Hip Replacement Spinal Fusion Dental Implant Gastric Sleeve Gastric Bypass Lap Band Liposuction Tummy Tuck Breast Implant Rhinoplasty Face Lift Hysterectomy Lasik (Both Eyes) Cornea (Both Eyes) Retina IVF Treatment USA $ 144.000 $ 57,000 $ 170,000 $ 50,000 $ 50,000 $ 50,000 $ 100,000 $ 2,800 $ 28,700 $ 32,927 $ 30,000 $ 9,000 $ 9,750 $ 10,000 $ 8,000 $ 15,000 $ 15,000 $ 4,400 Not Provided Not Provided $ 14,500 Thailand $ 15,121 $ 3,88 $ 21,212 $ 7,879 $ 15,152 $ 12,297 $ 9,091 $ 3,636 $ 13,636 $ 16,667 $ 11,515 $ 2,303 $ 5,000 $ 2,727 $ 3,091 $ 3,697 $ 2,727 $ 1,818 $ 1,800 $ 4,242 $ 9,091 Malaysia $ 11,430 $ 5,430 $ 10,580 $ 7,500 $ 12,350 $ 7,000 $ 6,000 $ 354 Not Provided $ 9,540 Not Provided $ 2,299 Not Provided Not Provided $ 1,293 $ 3,440 $ 5,250 $ 477 Not Provided $ 3,000 $ 3,819 India 5.200 3,300 5,500 7,000 7,000 6,200 6,500 1,000 5,000 5,000 3,000 2,800 3,000 3,500 4,000 4,000 2,500 500 Not Provided 850 3,250

Medical Tourism in South Asia

Sri Lanka Sri Lankas health care sector has undergone an enormous boom in recent years and has become a global health destination offering some of the best medical treatments in the world, the countrys growing reputation as a preferred health and medical estimation sees it welcoming visitors from around the world seeking remedies for a range of medical needs. Renowned for the hospitality of its people, this tear drop shaped island boasts amazing diversity for a location so compact. From white sandy beaches to verdant rainforests, undulating hillsides and a rich historical landscape whatever your preference is, Sri Lanka promises to be the ideal destination. Quite apart from its tourism appeal Sri Lanka also boasts the highest literacy rate in the region and a strong heritage in ayurvedic medicinal treatments, adding to the countrys appeal as a top Asian destination for medical tourism. With some of Asias most technologically advanced and a superior medical history, Sri Lanka is undoubtedly one of the world top Medical Tourism destinations. It welcomes visitors from around the world seeking remedies for a range of medical needs. Also, Sri Lanka offers quality cosmetic surgery at low prices. Sri Lanka has an excellent private medical network with highly trained and qualified (mostly English speaking) doctors and surgeons, many with qualifications from the UK, Australia and the USA. They are supported by experienced and highly trained medical staff at modern, "state of the art" fully equipped, wellstaffed private medical centers with excellent diagnostic and treatment resources. 42

Though the medical tourism industry in Sri Lanka is still in its early days, a number of private hospitals in Colombo are well geared to provide services to international clients. Among the best known of these include the Apollo Hospital, Asiri Hospital Group, Durdans Hospital, and Nawaloka Hospital. All of these are equipped with state-of-the-art technology and equipment, and offer the latest in diagnostics, medical and surgical services. Pakistan Medical tourism in Pakistan is viewed as an untapped market that could be turned into a huge opportunity if the government "focuses on key issues". According to Pakistani medical experts, Pakistan has a "huge potential" in becoming a regional medical tourism hub, comparable to many other countries in its neighborhood. Medical tourism in Pakistan has been arranging potential trips for many medical health and care procedures. A number of modern hospital facilities exist in major cities such as Islamabad, Karachi and Lahore that are fully equipped and facilitated with the latest medical technologies. Many doctors and surgeons in Pakistani hospitals tend to be foreign qualified. However, security issues and an overall below-par health infrastructure have challenged the growth of the industry. Already, a number of patients from places such as the Middle East, UK and US seek a range of treatments in Pakistan; these include cardiac surgery, infertility treatments and cosmetic surgery. Costs for treatment in Pakistan are more than 50% of what doctors and hospitals charge abroad. At the moment, most foreign patients who come here for treatment are of Pakistani origin. Liposuction can cost between Rs0.7-0.8 million abroad, while the same procedure here can be done within Rs0.2 million. Pakistans initial entry into the medical tourism industry has been strongly reliant on cheap organ transplant tourism. In the past, a sizable number of global patients traveled to Pakistan for kidney transplants. However, these cases have dropped ever since legislation, that sought to outlaw the illegal trade of selling kidneys, was enacted. According to Pakistani medical experts, medical tourism is still an untapped market that could be turned into a huge opportunity if the government "focuses on key issues.

India
India is located in South Asia and is the seventh-largest country in this area in terms of area. The country is surrounded by the Indian Ocean, Bay of Bengal and Arabian Sea. The Indus Valley Civilization thrived here and till today the country is linked with cultural wealth. Four of the major world religious originated in this country, namely Hinduism, Jainism, Buddhism and Sikhism. India is an electric amalgamation of diverse ethnic groups. The different cultures that exist in this country make it a rich experience for travelers. From its ancient heritage to intricate cuisine, India tourism has a lot to offer travelers. You can spend your day on beaches, amongst snowcapped mountains or even being whisked away by some colorful, vibrant festival. Medical tourism and health care in India is a rapidly expanding sector. The cost of medical treatment is negligible as compared to the western world and India can offer the most advanced health care. Medical tourists travel to India to get the best in terms of health care and also to experience the country's rich culture. Why Medical Tourism in India A strong system of healthcare in India has made it a much sought after destination for medical services. The country is known for its high quality and world class medical facilities that boast economical pricing, robust infrastructure and top notch health care services. International patients from countries in the neighborhood such as Bangladesh, Pakistan, Afghanistan, Sri Lanka, and Maldives are coming to India for medical care. Medical tourists seeking medical services from the US, UK, Europe and many African countries have also been impressed with the Indian commitment to quality and affordable pricing. 1. High standards in medical, surgical care and patient handling Many hospitals and health centers specialize in certain fields such as cardio thoracic surgery, dentistry, ophthalmology, etc. Many healthcare facilities organize seminars and conferences where they invite leading 43

doctors from around the world. World class diagnostic centers, blood banks and imaging centers have been set up. 2. Low cost treatment The cost of getting treatment in India is very low even when comparing with other medical tourism countries. It is at the most 10% to 20% of what will be charged in the US or UK. Above all you will find the same standards upheld that you would have found in your country. 3. Fluent English speaking hospital staff There is high professionalism in the Indian medical industry. All doctors, nurses and most paramedical staff will speak to you in English. Now you don't have to worry about not being understood. And this eliminates the need for a translator. 4. Waiting times for surgeries and other treatment is lower than in other countries Many patients come to India after learning that they would have to wait for months to undergo a similar surgery in their country. Rather than waiting for a long time and suffer in the meanwhile, flying abroad for medical treatment is a much better option. 5. A large number of private hospitals where the medical facilities and serving doctors can be compared to the best in the world Hospitals and clinics in India are constantly acquiring the latest equipment and state-of-the-art technology to deliver the widest range of services. Many hospitals have also started international patient wards with special desks that cater to the travel requirements, translation and dietary requirements of international medical tourists exclusively. 6. State of the art technology available to treat even the most difficult medical cases India is known for medical treatments where advanced healthcare is required, such as organ transplants, cardio-vascular surgery, eye surgery, etc. Indian hospitals are equipped with high end technologies such as Gamma knife, Cyberknife, IMRT, brain suite, Novelix TX, PET Scan, IGRT, etc. 7. Availability of traditional/alternative healing systems like Ayurveda, Yoga, Ayush, Siddha, Unani and Naturopathy If you are looking for holistic healing centers for alternative procedures, then India is a well known medical tourism destination where you can access traditional and highly recommended treatments like the world renowned Ayurveda, yoga, meditation and naturopathy. 8. India has many tourist attractions that offer healing environs and other rewarding experiences India has a rich cultural and historical past, and is well connected to all places by train, bus and flight. Travel is also very economical and easy. When you are done with your medical procedure, you can visit the many tourist destinations in India. Many of the people who come to India for health tourism end up visiting the country. Health Care System and Quality in India Healthcare services in India have always been a combination of traditional methods and modern medicine. Until a few decades ago, most hospitals were government run. But off late, health care in India has been transformed. Hospitals these days are either corporate or private and ensure their customer are given world-class service. Corporate hospitals are required to give equal care to people who may be a little economically backward as well. The doctors who work at these hospitals are highly skilled and provide a high quality of health care. Hospitals and Doctors Standards in India High end technology is used in most hospitals and specialists take care of complex treatments like joint replacements, heart surgery and neurosurgery. The education and accreditation system of hospitals and doctors in India are extremely strict and well regulated. A large percentage of doctors specialize abroad in counties like Germany, the UK, Australia and the States, bringing quality standards from the western world to India. India's private health care is booming and will soon be worth billions of dollars. India has set up expertise in complicated sectors like cardiac care, ophthalmology and cosmetic surgery. All clinics and health care providers are thoroughly and carefully assessed before being licensed, leaving little room for any form of negligence. Hospital standards and the services offer by doctors are of the highest quality. The combination of low cost health care and the chance to experience some of the world's most ancient cultures attracts people from all over the world to India for medical tourism. 44

India Visa Requirements for Medical Tourists People seeking medical treatments in India can receive a Medical Visa if their care is being handled by a reputable, licensed healthcare facility. Up to two traveling companions blood relatives only are permitted to accompany the patient if they have obtained separate Medical Attendant Visas, which have the same validity as the Medical Visa. Some of the ailments/procedures that are given preference include neuro-surgery, ophthalmic disorders, heart problems, renal disorders, organ transplants, congenital disorders, gene therapy, plastic surgery, and joint replacement. The visa is valid for up to one year, of for the duration of the procedures, whichever is less, and is valid for up to three separate entries over that time period.

Maldives
Maldives is a tourist country and there are millions of tourists arriving in Maldives every year. There are about 90 high class resorts in Maldives but when we look into Medical Tourism, its equivalent to NO. Reason for not promoting Medical Tourism in Maldives is the lack of Health facility and the cost of Health facility is very high. There are some Government Hospitals in different Atolls in Maldives. The biggest hospital is Indira Gandhi Memorial Hospital or IGMH and the only private Hospital is ADK Hospital. Tourists use these facilities in case of emergencies and not as a Medical Tourism Concept. There are few private clinics like AMDC which provide service as a Day clinic. Reference http://www.redorbit.com/news/health/1112923327/asian-medical-tourism-market-forecast-to-2015/ www.oecd.org/els/health-systems/48723982.pdf http://www.mymedholiday.com/blog/index.php/2013/03/159/six-countries-in-asia-make-the-top-ten-listof-medical-tourism-destinations/ http://www.mtqua.org/2013/06/13/2013-top-10-hospitals/ http://www.mymedholiday.com http://www.singaporemedicine.com/index.asp http://finance.yahoo.com/news/research-markets-booming-medical-tourism-162600481.html https://editorialexpress.com/cgi-in/conference/download.cgi?db_name=SERC2013&paper_id=230 www.mymedholiday.com/country/malaysia http://www.kish.in/medical-tourism-in-maldives/ http://en.wikipedia.org/wiki/Medical_tourism_in_Pakistan http://tribune.com.pk/story/365757/untapped-market-can-pakistan-become-a-hub-for-medical-tourism/ http://www.channelnewsasia.com/news/health/medical-tourism-in/735950.html

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CHAPTER-4 INDIA: A HUB FOR HEALTHCARE

The healthcare industry includes medical care providers, physicians, specialists clinics, nursing homes, hospitals, medical diagnostic centers, and pathology laboratories. In terms of revenue and employment, healthcare is one of Indias largest service sector industries. During the 1990s, Indian healthcare grew at a compound annual rate of 16%. The total value of the sector is more than $34 billion. This translates to $ 34per capita, or roughly 6% of GDP. By 2012, Indias healthcare sector is projected to grow to nearly $40 billion. There are over 3,371 hospitals and around 754,985 registered practitioners catering to the needs of traditional Indian healthcare. The medical tourism market in India has witnessed a rapid growth over the past few years. India has become a hub for medical tourists due the growing popularity of traditional alternative therapies, such as ayurveda, therapeutic massage, yoga, and meditation among the tourists. Moreover, improvements in the medical infrastructure with a growing pool of qualified specialists, is attracting medical tourists from all across the globe. World class treatment at almost 1/10th of the cost with no waiting time for surgeries as compared with advanced nations like the UK and the USA have been instrumental in a large number of foreign arrivals to access health care services in India. The medical tourism market in India is valued to be worth over US$ 310 million with 100,000 foreign patients coming in every year. Indias medical tourism sector is expected to experience an annual growth rate of 30%, making it a $3.9 billion industry by 2015 from $1.9 billion in 2011. According to a report published by RNCOS, Indias share in the global medical tourism industry will reach around three per cent by the end of 2013. Study by ASSOCHAM reported that the year 2011 saw 850,000 medical tourists in India and projected that by 2015 this number would rise to 3,200,000.

Medical Toursim Market in India (USD Billion)

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 2011 2014 1.9 3.9

CAGR 27%
Medical Toursim Market in India

Source: Ministry of Health, RNCOS, KPMG, Aranca Research Reasons for Medical Tourism in India: India is the largest democracy in this world India is an English speaking country India offers both traditional and alternative healthcare practices Indian doctors have proven their skills globally and are well known for their excellent credentials and hard working nature India also offers lower costs for healthcare treatment and hence is more competitive 46

It is estimated that 75-80% of health care services and investments in India are now provided by the private sector. It is self sufficient in drug production and exports drugs to more than 180 countries. A medical visa has been introduced which can be given for a specific purpose to foreign tourist coming to India for medical treatment. This visa is issued to a patient with a companion for a period of one year. It can be extended up to three years subject to terms, conditions and recommendations from the accredited medical authorities.

Some of the corporate hospitals in India that lead the medical tourism revolution are: Escorts Heart Institute & Research Centre Medanta The Medi city Apollo Hospitals Aravind Eye Hospitals Dr. Vivek Saggar's Dental Care & Cure Centre NM Excellence LV Prasad Eye Institute B.M.Birla Heart Research Centre Christian Medical College Tata Memorial Cancer Hospital

Fortis Healthcare

Max Hospital

Manipal Hospital PD Hinduja National Hospital & Medical Research Centre

Wockhardt Hospitals

Leelawati Hospital

Countries Visiting India for Medical Tourism

Source Market (%)

2% 2% Westerners (US and Europeons) 10, 10% Middle Easterners (Oman, Iraq, UAE) Africans (Nigeria, Tanzania, Kenya, Gambi a ets) South Asians (Bangladesh, Pakistan, Sri Lanka, Nepal, Burma) East Asians (Far east, South East Asia)

35%

51%

Major Areas of Healthcare Indias rich cultural history affords many holistic forms of treatments like the 3000- year old ayurveda, yoga, siddha, unanni and other ancient treatment modules. Ayurveda and yoga have captured the imaginations of westerners like no other ancient healthcare philosophies. South India especially Kerala is sprinkled with ayurvedic medical spa resorts and meditation centers where a host of western medical tourists pay big money for health packages that include de-stressing, body toning, weight loss and healing of aches and pains like sinusitis, backaches and so on. These treatments last for a period of 3 21 days and mostly involve 47

herbal remedies. Meditation centers teach yoga and other ancient meditation techniques that help to heal the spirits of over-worked, tired and exhausted westerners.

Ayurveda

Medispa Healthcare in India

Naturopathy

Yoga

Meditation

Naturopathy Naturopathy is an art and science of healthy living and a drugless system of healing based on well founded philosophy. It is a form of alternative medicine based on a belief in vitalism, which posits that a special energy called vital energy or vital force guides bodily processes such as metabolism, reproduction, growth, and adaptation. Naturopathy favors a holistic approach with non-invasive treatment and generally avoids the use of surgery and drugs. Among naturopaths, complete rejection of biomedicine and modern science is common. Indian Naturopathy movement started mainly in the States of Andhra Pradesh, Uttar Pradesh, Bengal, Maharashtra and Gujarat. The Naturopaths who did foundation work in revival of Naturopathy in different States are Dr. Mahavir Prasad Poddar, Dr. Janaki Sharan Varma, Shri Sharan Prasad, Dr. Khushi Ram Dilkash, Dr. S.J. Singh, Dr. Hiralal, Dr. Vitthal Das Modi, Dr. Kulranjan Mukherjee, Dr. Sukhram Das, Dr.J.M. Jussawala,Dr. M.M. Bhamgara, Dr. Vegi Raju Krishnam Raju, Dr. B. Venkat Rao, Dr. B. Vijaya Laxmi, Dr. Ganga Prasad Gaur Nahar, Shri Dharam Chanda Saravagi, Dr. Sukhbir Singh Rawat, Acharya K. Laxman Sharma etc. The main features of Naturopathy are as under: 1. All diseases, their causes and treatment are one. Except for traumatic and environmental conditions, the cause of all diseases is one i.e. accumulation of morbid matter in the body. The treatment of all diseases is elimination of morbid matter from the body. 2. The primary cause of disease is accumulation of morbid matter. Bacteria and virus enter and survive in the body only after the accumulation of morbid matter when a favourable atmosphere for their growth is established in body. Hence, the basic cause of disease is morbid matter and bacteria. 3. Acute diseases are self-healing efforts of the body. Hence, they are our friends, not the enemy. Chronic diseases are outcome of wrong treatment and suppression of the acute diseases. 4. Nature is the greatest healer. The human body itself has the healing power to prevent itself from disease and regain health if unhealthy. 48

5. Naturopathy Cures Patients suffering from chronic ailments are also treated successfully in comparatively less time by Naturopathy. 6. In Nature Cure the suppressed diseases are brought to surface and are removed permanently. Naturopathy treats the body as a whole. 7. According to Naturopathy, Food is only the Medicine, no external medications are used. 8. Performing prayer according to ones spiritual faith is an importa nt part of treatment (According to Gandhiji Rama Nama is the best Natural Treatment. Yoga and Meditation For years, travelers seeking serenity and spiritual renewal have made their way to India's ashrams and retreat centers to learn the wisdom of ancient practices like yoga, meditation and Ayurveda healing. Whether you're looking for a disciplined daily meditation routine at a spiritual center or a luxury spa with a focus on wellness and healing, the country's many retreat centers all promise visitors stress reduction, self-discovery and an escape from a busy urban lifestyle. Yoga The word "Yoga" came from the Sanskrit word "yuj" which means "to unite or integrate." Yoga then is about the union of a person's own consciousness and the universal consciousness. Ancient Yogis had a belief that in order for man to be in harmony with himself and his environment, he has to integrate the body, the mind, and the spirit. For these three to be integrated, emotion, action, and intelligence must be in balance. The Yogis formulated a way to achieve and maintain this balance and it is done through exercise, breathing, and Meditation - the three main Yoga structures. In yoga, the body is treated with care and respect for it is the primary instrument in mans work and growth. Yoga exercises improve circulation, stimulate the abdominal organs, and put pressure on the glandular system of the body, which can generally result to better health. Breathing techniques were developed based on the concept that breath is the source of life. In Yoga, students gain breathing control as they slowly increase their breathing. By focusing on their breathing, they prepare their minds for the next step - Meditation. There is a general misconception that in Meditation, your mind has to go blank. It doesn't have to be so. In Meditation, students bring the activities of the mind into focus resulting in a 'quiet' mind. By designing physical poses and Breathing Techniques that develop awareness of our body, Yoga helps us focus and relieves us from our everyday stress. Meditation is a practice in which an individual trains the mind or induces a mode of consciousness, either to realize some benefit or as an end in itself. The term meditation refers to a broad variety of practices (much like the term sports) that includes techniques designed to promote relaxation, build internal energy or life force and develop compassion, love, patience, generosity and forgiveness. A particularly ambitious form of meditation aims at effortlessly sustained single-pointed concentration single-pointed analysis, meant to enable its practitioner to enjoy an indestructible sense of well-being while engaging in any life activity. Yoga Tourism as a function within the Wellness Tourism Market YOGA TOURISM is a new concept for "Celebrating Your Destination with YOGA". A generally accepted idea by the foreigners is that India is a land of billions of people, of millions of gods, of great variety of religions, of enormous number of temples, of philosophers and sadhus or saints, of festivals and fares, of deserts and hills, of cows and snakes etc. There is another thing that India can offer and for which she is also famous. That is its millennia ancient wisdom on how to preserve and improve man's physical and mental health and how to achieve spiritual growth. India has experienced many ups and downs due to invasions, wars and robbery by various rulers. But there is one thing that has never changed from time immemorial and remains standing, as the emblem of India, and it is its ancient wisdom. Some of the names of yoga centers in India are: Ramamani Iyengar Memorial Yoga Institute, Pune Ashtanga Yoga Research Institute, Mysore Krishnamacharya Yoga Mandiram, Chennai Sivananda Yoga Vedanta Dhanwantari Ashram, Trivandrum Parmarth Niketan, Rishikesh Medi-Spa 49

A medical spa is a hybrid between a doctors office and a day spa. Medical spas operate under the full-time supervision of a licensed medical professional in a spa-like setting. When visiting a medical spa, patients can be pampered with traditional spa services but also have the option of getting medical services like Botox, laser hair removal, and medical-grade skin therapies. The medical professionals of the med spa are licensed, educated and trained in the medical procedures and treatments provided to ensure the highest level of care for every patient. While many medical spas focus on providing their clients with the latest emerging non-invasive cosmetic procedures, many others focus on teaching their clients about alternative medicine techniques for healing and health. These medical spas perform services such as aromatherapy and acupuncture, as well as traditional spa services. These spas are also of benefit to people who are interested in learning about natural methods of weight and disease control. Another common type of medical spa is a more nutrition and education-based facility. These medical spas teach their clients about different procedures and lifestyle changes that can help them reduce the amount of suffering caused by a certain disease or condition. For example, many medical spas educate their clients on ways to control diabetes and obesity. Another commonly addressed medical issue is menopause. Massage magazine reports medispas are one of the fastest growing segments in the wellness industry. entrepreneur.com recently calculated their growth at 23 per cent a year. Medispas are the fastest-growing segment of the spa industry with estimated annual revenue of $450 million for doctor-run medispas. According to Eric Light, president of the International Medical Spa Association, they have an annual growth rate of 11 per cent to 14 per cent. Ayurveda Ayurvedic medicine also known as Ayurveda is one of the world's oldest holistic (whole-body) healing systems. It developed thousands of years ago in India. Ayurveda can be defined as a system, which uses the inherent principles of nature, to help maintain health in a person by keeping the individual's body, mind and spirit in perfect equilibrium with nature. The primary focus of Ayurvedic medicine is to promote good health, rather than fight disease. But treatments may be recommended for specific health problems. In the U.S., Ayurveda is considered a form of complementary and alternative medicine . What is 'Panchakarma' or the Therapy of Purification: If toxins in the body are abundant, then a cleansing process known as panchakarma is recommended to purge these unwanted toxins. This fivefold purification therapy is a classical form of treatment in ayurveda. These specialized procedures consist of the following: Therapeutic vomiting or emesis (Vaman) Purgation (Virechan) Enema (Basti) Elimination of toxins through the nose (Nasya) Bloodletting or detoxification of the blood (Rakta moksha) Every person is made of a combination of five basic elements found in the universe:

Space Air Fire Water Earth These elements combine in the human body to form three life forces or energies, called doshas. They control how your body works. The three doshas are:

50

Doshan

It Controls

Vata Dosha

If vata dosha is your main Things that can disrupt life force, you are more this dosha are: likely to develop: anxiety mind eating dry fruit asthma breathing eating too soon after heart disease a previous meal blood flow nervous system fear heart function disorders ability to get rid of grief rheumatoid arthritis body waste through staying up too late skin problems the intestines anger and negative emotions Crohn's disease heart disease heartburn a few hours after eating high blood pressure infections

Pitta Dosha

digestion ability to break down foods (metabolism) certain hormones linked to appetite

eating sour foods eating spicy foods fatigue spending too much time in the sun daytime sleeping eating after your stomach is full eating or drinking items that have too much salt or water eating too many sweet foods greed

Kapha Dosha

muscle growth body strength stability weight immune system

and

asthma and other breathing disorders cancer diabetes nausea after eating obesity

Medical Tourism in India Medical Tourism has been rapidly increasing in India in the recent years. Indias share in Medical Tourism in the world is expected to reach around 3% by 2013 which is quite creditable. There are many factors contributing to such a rapid growth in Medical Tourism. One of the main factors is that the medical treatment in India is less expensive as compared to the rest of the world. Not only low cost but a quality treatment at a low cost is the main factor which brings patients from all across the world to India for treatment. The doctors and surgeons in India are so very skillful and well trained and the staff in most of the Indian Hospitals including the nurses is also well educated and trained in their respective fields. Most of the hospitals in India are well equipped as well. The Government of India has also introduced the Medical Visa for backing medical tourism in India. According to the Press Release by the Press Information Bureau the Ministry of Tourism, the Government of India provided assistance to 10 Medical Tourism service providers by sanctioning an aid of 27742 US$. Indian medical tourism is expected to generate revenue worth $300 crore by 2013, growing at a CAGR of around 26 per cent during 2011-2013. It is further expected that it would cross 6200 crore in 2020 and 2 lakh crore in 2025. The number of medical tourists is anticipated to grow at a CAGR of over 19 per cent during the forecast period to reach 1.3 million by 2013.

51

No. of Medical Tourists arrival in India (in Lakhs)

60 50 40 30 20 10 0 2011 2012 F 2013 F 2020 F 2025 8.5 11 13 49

24

Medical services being offered in India under a medical tourism package Complete dental treatment Complete eye care treatment Orthopedics and trauma Cardiac care including surgery Urology including endourology Neurosurgery Plastic and cosmetic surgery Laparoscopic surgery Gastroenterology Kidney transplant SWOT analysis SWOT, which is the acronym for strengths, weaknesses, opportunities and threats, is also known as WOTSUP or TOWS analysis. SWOT analysis is done by various businesses and organizations in order to understand the various external and internal environment. Through such an analysis, the strengths and weaknesses existing within the medical tourism can be matched with the opportunities and threats operating in the Indian environment so that an effective strategy can be formulated. Some of the primary environmental influences operating currently in the context of the Medical Tourism in India. Medical Tourism: SWOT approach. Business, service firms undertake SWOT analysis to understand their external and internal environments. Through such an analysis, the strengths and weaknesses existing within the medical tourism can be matched with the opportunities and threats operating in the Indian environment so that an effective strategy can be formulated. Some of the primary environmental influences operating currently in the context of the Medical Tourism in India. Strengths Strengths are the inherent capacity of an organization which can be use to gain strategic advantage. An example of strength is superior research and development for a new service industry development so that the industry can gain a strategic advantage. The strengths in medical tourism are:

Quality and Range of Services. 52

India has number of hospitals offering world class treatments in nearly every medical sector such as cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. The various specialties covered are Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Pediatrics, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery. For its quality of services and the infrastructure available, India is attracting a vast pool of tourists from the middle east, Africa etc. Affordable cost: In addition to cultural and scenic beauty, India is now being put up on international map as a heaven for those seeking quality and affordable healthcare. With 50 million Amercians without health insurance and waiting lists for state- run facilities often endless in the UK, Canada and Europe, foreigners are increasingly flocking to India for the healthcare or medical services that are available at fifth of the cost what is charged in abroad. In India, complicated surgical procedures are at 1/10th the cost as compare with the procedures in the developed countries. Vast supply of qualified doctors: India has a Large pool of doctors (approx 600000), nurses & paramedics with required specialization and expertise and the language advantage ( English speaking skills).The medical education system caters to the ever increasing demand for the delivery of the quality healthcare services all over the country. India is also amongst the top countries for strong presence in advanced health care. Eg. Cardiovascular, Organ transplants-high success rate in operations with international Reputation of hospitals and Doctors. Internationally reputed hospitals are: Apollo hospitals group located at Delhi, Chennai, Hyderabad & Madurai, Escorts heart institute & research centre located at Delhi and Faridabad, Dr, Vivek Sagars Dentalcare &cure centre located at Ludhiana, PD. Hinduja National Hospital & Medical Research Centre located at Mumbai, LV. Prasad Eye Institute located at Hyderabad. Top class luxury resorts A destination resort provides a wide variety of experiences and facilities to keep guests occupied in one location for a month or more. These luxury resorts denote finer hospitality and best comfort that money can buy. The places are like manmade heaven on the earth and few hospitality places are: o Kumarakom Lake Resort in Kerala, is a wonderful blend of traditional architecture, natural beauty and great service and as close to nature as it can get. o The Leela, Goa designed to reflect Goas Portuguese and Indian heritage, The Leela, Goa, pampers guests with a choice of luxurious villas, suites or rooms characterized by plush furnishings and serene ocean views. The Leela Palace, Goa, has won the World Travel Awards as Asias leading luxury resort for three years in a row. o The Oberoi Rajvilas, Jaipur is an oasis of elegance and luxury, offering consistently high standards of facilities and services. o Taj Exotica, Goa a tranquil corner of the world steeped in sepia-tinted romantic history. With tropical dcor, its grand architecture, a lush sun-drenched atrium, wide shady corridors and flowerlined patios, every corner of the Taj Exotica is a retreat itself. One of the highlights at the Taj Exotica is that each room offers a panoramic view of the sea, whether it is from ones own private balcony or from the generously appointed terraces. Weakness A weakness is an inherent limitation or constraint which creates strategic disadvantages. An example of a weakness is overdependence on a single service line, which is potentially risky for a service industry in times of crisis. The weaknesses are as follows: No strong government support/ initiative to promote medical tourism. Low coordination between the various players in the industry- airline operators, hotels, and hospitals. Lack of uniform pricing policies across hospitals. 53

 Political problems etc. Opportunities An opportunity is a possibility for service industry sector to strengthen its postion. The following are opportunities in medical tourism. Increased demand for healthcare services from countries with aging population (US, UK) Fast-paced life style increases demand for wellness tourism and alternative cures. Shortage of supply in National Health Systems in countries like UK, Canada. Demand from countries with underdeveloped healthcare facilities. Demand for retirement homes for elderly people especially Japanese. Personal touch by the doctors in India. Traffic system is well developed and easy to go from one country to another country. Medicines and labour cost is low as compared to developed countries. Threats A threat is an unfavorable condition in the industrys environment which creates a risk for, or causes damage to, the industry. Some of the threats for medical tourism industryare: Strong competition from countries like Thailand, Malaysia and Singapore. Lack of international accreditation a major inhibitor. Overseas medical care not covered by insurance providers. Under investment in health infrastructure. Identifying a real practitioner is a major problem in India. Exploitation of tourists by illegal money changers. Strength Weakness Quality Service at Affordable Cost No strong government support /initiative to promote medical tourism Vast supply of qualified doctors Low Coordination between the Strong presence in advanced healthcare various players in the industryairline e.g. cardiovascular, organ transplants operators, hotels and hospitals high success rate in operations Customer Perception as an unhygienic International Reputation of hospitals and country Doctors No proper accreditation and regulation High confidence level in Indian doctors system for hospitals Diversity of tourism destinations and Lack of uniform pricing policies across Experiences hospitals Opportunity Threat Increased demand for healthcare Strong competition from countries services from countries with aging like Thailand, Malaysia, Singapore population (U.S, U.K) Lack of international accreditation Fast-paced lifestyle increases demand a major inhibitor for wellness tourism and alternative Under-investment in health cures infrastructure Shortage of supply in National Health Lack of proper insurance policies Systems in countries like U.K,Canada for this sector Reduced/competitive cost of international travel Propositions for future The following section lays down the strategies for India that can act as a driving force to achieve top position in medical tourism industry. Role of Government The role of Indian Government for success in medical tourism is two-fold: Acting as a Regulator to institute a uniform grading and accreditation system for hospitals to build consumers trust. Acting as a Facilitator for encouraging private investment in medical infrastructure and policymaking for improving medical tourism. 54

For facilitating investment the policy recommendations include: Recognize healthcare as an infrastructure sector, and extend the benefits under sec 80-IA of the IT Act. Benefits include tax holidays for five years and concessional taxation for subsequent five years. The government should actively promote FDI in healthcare sector. Conducive fiscal policies - providing low interest rate loans, reducing import/excise duty for medical equipment. Facilitating clearances and certification like medical registration number, anti-pollution certificate etc. For facilitating tourism the government should follow Hassel free visa process and visa-on-arrival for patients. a policy to increase inflow of flights into India. Create Medical Attachs to Indian embassies that promote health services to prospective Indian visitors.

Government Initiatives Initiatives of Ministry of Tourism to promote Medical Tourism Dedicated exhibition space for Medical Tourism in ITB, Berlin: In order to promote the positioning of India as a Medical destination and increase the presence of the medical fraternity in the international travel exhibitions, a dedicated space of 4 sq m. was provided to the medical fraternity within the India Pavillion at ITB Berlin. Road shows for promotion of Medical Tourism Road shows focusing on Medical Tourism are a continuous process and are organized in consultation with the Stakeholders from time to time. The last road show was organised in West Asia (Dubai, Riyadh, Kuwait and Doha) in October 2009 which was led by the Minister of State for Tourism. Production of Publicity Material Brochure, CDs and other publicity materials to promote Medical and health tourism have been produced by Ministry ot Tourism and have been widely circulated for publicity in target markets. Fiscal Incentives Provided by Ministry of Tourism for Development of Medical Tourism Salient Features of MDA for Medical Tourism For participation in approved Medical and other Tourism Fairs/Medical Conferences/Wellness Fairs and its allied Road Shows Ministry of Tourism provides Market Development Assistance. This scheme was extended to the Medical Tourism Service Providers and Wellness Tourism Service Providers during the year 2009. Financial support under the MDA Scheme is provided to approve medical tourism service providers, i.e. representatives of Hospitals accredited by JCI and NABH and Medical Tourism facilitators (Travel Agents/ Tour Operators) approved by Ministry of Tourism, Government of India and engaged in Medical Tourism. The Government of India has introduced the Medical Visa for backing medical tourism in India. Medical Visa is to seek medical treatment only in the reputed/recognized hospitals/treatment centers in India. Up to two attendants who are blood relatives are allowed to accompany the applicant visas, their visa validity will be the same as the medical visa. Duration and Validity The initial duration of the visa is up to a year or the period of the treatment, whichever is less. The visa will be valid for a maximum of 3 entries during the one year. The visa duration starts on the day of issuance, and not on the day of entry into India.

55

References

http://www.asa.in/pdfs/surveys-reports/Healthcare-Telemedicine-and-Medical-Tourism-in-India.pdf en.wikipedia.org/wiki/Medical_tourism_in_India www.ibef.org/download/healthcare-august-2013.pdf indiainbusiness.nic.in/newdesign/upload/.../Healthcare-March-220313.pdf http://www.scribd.com/doc/131593797/Healthcare-Industry-Report-March-2013 http://www.internationalexperts.com/index.php/research/item/medical-tourism-in-india http://www.publishingindia.com/Uploads/SampleArticles/JHAR-Sample-Article.pdf indianmedicine.nic.in Home About The Systems en.wikipedia.org/wiki/Naturopathy http://www.yogatourism.com/concept.htm http://www.americanmedspa.org/what-is-a-med-spa/ http://acne.about.com/od/professionalprocedures/f/WhatIsAMedicalSpa.htm voices.yahoo.com/what-medical-spa-150829.html en.wikipedia.org/wiki/Ayurveda http://www.webmd.com/balance/guide/ayurvedic-treatments http://smehorizon.sulekha.com/medical-tourism-to-generate-3-billion-by-2013report_pharmaceutical-viewsitem_1340 http://dspace.iimk.ac.in/bitstream/2259/577/1/ http://www.slideshare.net/jatinpatel1326/medical-tourism-in-india-with-special-focus-on-foreignpatients-satisfaction-level-for-healthcare-facilities-at-ahmedabad-and-vadodara

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CHAPTER-5 THE MEDICAL TOURISM SYSTEM

Tourism system is the framework that identifies tourism as being made up of a number of components, often taken to include the tourist, the tourist generating region, the transit route region, the tourist destination and the tourism industry. In the specific context of medical tourism, this can be broadly schematized as follows:

Medical tourism is an emerging global industry, with a range of key stakeholders with commercial interests including brokers, health care providers, insurance provision, website providers and conference and media services. These commercial interests are summarized as follow

57

Medical tourism and the web

A key driver in the medical tourism phenomenon is the technological platform provided by the internet for consumers to access healthcare information and advertising from anywhere in the world. Equally, the internet offers providers vital new avenues for marketing to reach into non-domestic markets. Commercialization is at the heart of the growth in medical tourism and in some part this is due to the availability of web-based resources to provide consumers with information, advertisements and market destinations, and to connect consumers with an array of healthcare providers and brokers. A review (Lunt et al., 2010) suggests the following typology of websites: portals (focussed on provider and treatment information) media sites consumer-driven sites commerce-related sites (providing ancillary services and information) professional contributions (from sources such as professional associations and state regulatory institutions are relatively rare).

58

Services Required : Medical Consultation from top notch consultants in India Professional medical care Medical Visa Assistance Pre and post Operative consultation overseas Tele- Conferencing facilities with the consultant Transport and accommodation assistance VIP transfers (airport-hotel-hospital/clinic) Guided tours Free translation services 24 hours emergency assistance

Major Medical Treatments in India Heart & Vascular Treatment Neurology and Spine Treatment Kidney Transplant Liver Transplant Bone Marrow Transplant Cosmetic Surgeries Fertility Treatments Gynecology Treatment Knee Replacement Hip Replacement Arthroscopy Eye Treatment Dental Treatment Hair Transplant Ayurveda and Spa Services

59

Laparoscopy Surgery Weight Loss Urosurgery and Endourology IVF and surrogacy Ear ,nose and Throat Surgeries Cancer Treatments Comprehensive Health Check Up

Medical Tourism Service Facilitator

60

Who is a Medical Tourism Facilitator

An Educator Your company; Destination options / centers of excellence; Accreditations, certifications, affiliations; Overseas providers; Overseas doctors; Travel considerations;

An Organizer Facilitating medical history, tests, etc for provider assessment; Facilitating medical complication insurance; Assisting with scheduling of medical appointments, after care, etc; Organizing transportation and hotel / recovery center stay; Assisting with flights;

A Bridge Many patients may know of a destination or provider of interest, but certain factors may come into play which leads them to you to help ease the process: Language barriers Time zone difference Dont know who to contact

An Advocate Ultimately, facilitator is a representative of the patient who is in a foreign country and in a vulnerable position; If there are issues with any part of the process, they need to be addressed immediately;

61

Getting Started the medical tourism Facilitator Business

Understanding Legal Issues: What is the liability and exposure as a facilitator of medical travel? Company Structure: What is the best company structure from a legal perspective, tax perspective, etc? Business Plan: This will establish your vision, goals, and generally keep you on track as you grow your company.

Essential Parts of the Set-Up

Establishing the Network What is going to be the focus: destinations, specialties, accreditations? This is a business of relationships, from hospitals, clinics, transportation companies, insurance companies, hotels / recovery centers; Choosing partners who will work with you efficiently is it is the key to success;

Legal Documents And Protection Patient waivers clearly outlining your role in the process; Clear understanding of patient privacy protection regulations; Liability insurance options for your company; Medical complication insurance offerings for patients;

Establish Patient Management Protocols Effective screening mechanisms: medical, psychological, and economic; Adequately matching patients with providers; Ensuring aftercare protocols are in place;

Create A Marketing Plan Who are you going to market to? Individuals? Corporate? How will you separate yourself from the competition? What marketing tools will you use? What is your marketing budget and acceptable burn rate?

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Medical Tourism Process

The job of a facilitator is both challenging and rewarding. There are a lot of logistical challenges that go into the successful management of a patient. The whole process is as follows Patient Contacts Medical Tourism Facilitator Facilitator Sends Client Initial Information On A Variety Of Destinations & Providers Facilitator Requests Medical History, Tests, Etc Which Will Help With Assessment Of The Case Providers Review Medical Records And A Quote Is Provided For The Procedure Conference Call With Doctor Procedure Scheduled Waiver Signed & Returned Clearly Outlining Role In The Process Deposit Or Full Payment Made: Commitment From The Patient Flight And Accommodations Arranged Patient Receives Detailed Itinerary and Information about Upcoming Medical Visit Patient Arrives At Destination, Is Met by A Representative, And Checks Into Hotel / Recovery Center Patient Is Welcomed By Healthcare Provider, Initial Consulation, Evaluation, Pre-Tests Patient Undergoes Procedure Patient Recovers Under Observation Of Health Provider Patient Is Discharged To Hotel Or Recovery Center And Follow-Up Protocols Initiated Follow-Up Evaluation With Doctor And Discharge From Care Patient Returns Home Facilitator Follows-Up With Patient And Monitors Recovery Process Leverage Positive Patient Experiences Successful Outcome And Satisfied Patient

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The business of medical travel is promising. More than 130 countries around the world are competing for a pie of this global business. It is generally estimated that the present global medical tourism market is estimated to be approximately US$ 40 billion with an annual growth rate of 20 percent.

A McKinsey (Ehrbeck, Guevara, & Mango, 2008) article suggests that though the market for medical travel has captured worlds attention and imagination, it isnt as large as reported. It further mentions that most medical travellers seek high quality and faster service instead of lower cost. On the basis of quality of medical treatment, authors segment buyers into 5 discrete types. The largest segment is 40 percent of all medical travellers. They seek worlds most advanced technologies. They are in search for high quality medical care available anywhere in the world, giving little attention to the proximity of potential destination or the cost of care. Example includes people travelling to developed countries for treatment. Second segment comprises of 32 percent market, include patients who seek better care then they could find in their home countries. They travel from under-developed and developing countries to developed countries. In selecting the destination, these patients generally trade-off perceived quality against burdens such as costs, distance and unfamiliar culture. The third segment, about 15 percent of the market, comprises of the medical patients who want quicker access to medically necessary procedure delayed by long wait times at home for orthopaedic and cardiac complications. 9 percent of the travellers represent the fourth segments that seek lower costs for medically necessary procedures. They seek to save significant part of the cost of treatment. The choice of destination for treatment is in accordance with the costs of treatment offered by the services providers. The last category representing a meagre 4 percent of market comprises of the patients seeking lower costs for discretionary procedures such as breast augmentation and reduction, liposuction etc. This segment seeks smaller but specialised service providers rather than larger multi-speciality hospital.

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Medical Tourism Segment:

Medical tourism value chain

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Value chain for international patients

Medical travel operators can be broadly classified into two groups. First, there are medical service providers such as hospitals and clinics. Hospitals that actively attract international patients are not involved only in the medical procedure itself, but are, in many cases, also responsible for all patient logisti cs from arrival to departure. Often the hospitals involvement starts before arrival with the processing of the visa requirements and ends only after departure with patient follow up. The second group consists of medical travel facilitators who function like agents and associated service providers. These are often smaller companies with just a few people on their payroll and most of them have spread their risk by dealing with hospitals and clinics in a number of different countries. Those medical travel agents which are dealing exclusively with hospitals of only one country or region are exposed to the same risks as the hospitals with which they work. These facilitators offer global health-care options that will enable international patients, primarily from source countries to access international health care at fraction of the cost of domestic care or shorter wait time. By selling a type of medical value travel, they focus particularly on the self-insured patient. Some companies charge clients a flat rate commission or a percentage of the total cost of care. Others do not directly charge customers, but are paid by the hospitals to which their clients travel for treatment. The companies typically provide experienced nurse care managers to assist patients with pre and post procedure medical issues. They also help provide resources for follow-up care upon the patient's return. Medical travel packages can include all costs associated with medical care, air and ground transportation, hotel accommodation, provision of a cell phone in the destination country for ease of communication, practical assistance from a local company representative at the health-care facility, travel arrangements for a companion, stays in nearby resorts during the post-operative recovery period and vacation to tourist destinations. For the purpose of this study a simple medical tourism value chain is considered. It broadly comprises of three components/ stages (Keckley & Underwood, 2008)

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Pre procedure stage

In this first stage the tourist is typically engaged in navigating the process and arriving at a decision to buy the procedure. A customer enters the procedure with search of relevant information from various sources. However, given the complexity many customers prefer to use services of an intermediary referred to as medical facilitator. Prime responsibility of the medical facilitator is to seamlessly coordinate the outbound medical tourism programme. Medical facilitators are intermediaries that guide the use of medical tourism for patients who find using their services more convenient and expedient than organising various service providers on their own. They offer single window solutions to the customers. They have experience in the medical tourism process and are able to address any concerns or questions that patients might have. Facilitators also provide assistance with logistics and travel arrangements. Patients may even be able to get lower rates from medical facilitator than directly from clinical programmes abroad (Keckley & Underwood, 2008). A medical tour operator is an important facilitator. Literature has referred to four types of medical facilitators- Medical Travel Planners, Travel Agencies, Hotel Groups and Provider Groups. Long before the actual medical procedure/ treatment, a customer must decide about a number of key issues, including the choice of facilitator, hospital, doctors, destination country, costs, conveniences, risks, etc. not necessarily in that order. Pre procedure stage typically ends with patient reaching the destination. The first stage of engagement is the pre-procedure stage where medical tourist feels the need, searches, identifies and finalizes the process of reaching to the destination for treatment. At this stage, the medical tourists appear to have five concerns- the quality of treatment, connectivity, the cost of treatment, the ease of access and the ease of purchase. Major concerns of medical tourists during the pre procedure stage

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Procedure stage
This is the key component of the medical tourism value chain. Procedure stage begins with patient reaching the destination and hospitals/ service providers offering pickup facilities followed by pre-counselling for treatment, necessary medical examinations required before the medical procedure. Medical procedure includes preparing for the procedure, organising a doctor and para medical team, operating theatre, procedure, prosthesis, medical supplies, etc. Major concerns of medical tourists during the procedure stage

Post procedure stage

Post procedure stage has two important components the post operative care and follow-up care. The post operative care includes doctors visits and monitoring for complications, recuperation in hospital and physical therapy, medical supplies, meals, post operative recuperation in destination country but outside the hospitals, etc. An important concern of medical tourist is the follow up care facilities long after they have left the country of treatment. Normally there is a tie-up between the medical service providers and doctors in the customers country who are responsible for follow up on behalf of service provider. After the post operative care when the tourist is fit to move around, he/ she may demand post treatment leisure as a part of the package.

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Proposed medical tourism value chain Following is the medical tourism value chain. This chain is adapted from Medical Tourism report produced by Deloitte Centre for Health Solutions. Based on discussions with service providers and feedback from respondents, certain changes in facilitator component of the value chain were made. Only 7 percent respondents used services of independent medical tour operator. Most medical service provider hospitals have vertically integrated a facilitation department which facilitated medical tourism for 77 percent of the respondents. Remaining 16 percent were supported by their respective governments. Main source of information for choosing medical facility abroad was friends and personal referrals (50%). 29 percent were referred by the doctors who they consulted at home. Only 7 percent relied on medical consultant. 2 percent were provided information by their insurance company while 4 percent searched for information on internet. Less than 1 percent relied on information advertised by service provider. This indicates that customers rely more on referrals from friends and consulting doctor at home. For medical tourists segments visiting India facilitation is organised by Doctor and hospital referrals in home country Government depar tment in home country Insurance Company Medical tour operators

International healthcare accreditation

International healthcare accreditation is the process of certifying a level of quality for healthcare providers and programs across multiple countries. International healthcare accreditation organizations certify a wide range of healthcare programs such as hospitals, primary care centers, medical transport, and ambulatory care services.

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The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation, which accredited the Bermuda Hospital Board as soon as 1968. Since then, it has accredited hospitals and health service organizations in ten other countries. In the United States, the accreditation group Joint Commission International (JCI) has been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999.[citation needed] Many international hospitals today see obtaining international accreditation as a way to attract American patients. Joint Commission International is a relative of the Joint Commission in the United States. Both are US-style independent private sector not-for-profit organizations that develop nationally and internationally recognized procedures and standards to help improve patient care and safety. They work with hospitals to help them meet Joint Commission standards for patient care and then accredit those hospitals meeting the standards. QHA Trent Accreditation, based in the UK, is an active independent holistic accreditation scheme. The different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill and intensity of their marketing. They also vary in terms of cost to hospitals and healthcare institutions making use of them. A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent. Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, QHA Trent for potential British and European clientele, and Accreditation Canada. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics. In India also hospitals are accredited by Joint Commission International (JCI) and National Accreditation Board for Hospitals and Healthcare Providers (NABH) and Medical Tourism facilitators (Travel Agents/Tour Operators) approved by Ministry of Tourism, Government of India for medical Tourism Other organizations providing contributions to quality practices include: The United Kingdom Accreditation Forum (UKAF) is an established network of accreditation organisations with the intention of sharing experience good practice and new ideas around the methodology for accreditation programmes, covering issues such as developing healthcare quality standards, implementation of standards within healthcare organisations, assessment by peer review and exploration of the peer review techniques to include the recruitment, training, monitoring and evaluation of peer reviewers and the mechanisms for awards of accredited status to organisations.

Top Super Specialty Hospitals for Medical Tourism in India

Name of Hospital Apollo Hospital Ms. Rekhanjali International Patient Division Indraprastha Apollo Hospitals Sarita Vihar, Mathura Road, New Delhi - 110076 India Phone: +91-11-26925801 / 26925858 Fax : +91-11-26825595 E-mail: assistance@apollohospitalsdelhi.comhttp://www.apollohospitals.com/ Vijaya Medical & Educational Trust (VMET) Vijaya Hospital: No.434, N.S.K.Salai, Vadapalani, Chennai -6000 26; Ph: 6664 6600 http://www.vijayahospital.org/ Speciality Treatments o Liver Transplant o Bone Marrow Transplant o Hand & Microsurgery o Infertility Care o Cosmetic Surgery o BirminghamHip Resurfacing o Bariatric Surgery(To remove obesity)

Fortis Healthcare Ltd (Corporate Office) Tower A, Unitech Business Park, Block - F, South City 1, Sector - 41,

Vijaya Hospital (VH), Vijaya Health Centre (VHC), Vijaya Institute of Trauma & Orthopaedics (VITO) and Vijaya Heart Foundation (VHF) & Vijaya Eye Foundation Anaesthesiology Clinical Nutrition and Dietetics Colorectal Surgery Cosmetic Surgery Critical Care Dental

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Gurgaon, Haryana- 122001 Contact Numbers : +91 124 4921033, +91 124 4921021 , +91 124 4921071 Fax number : +91 124 492 1041 Email id : contactus@fortishealthcare.com enquiries@fortishealthcare.com http://www.fortishealthcare.com Major Hospitals are in:

Amritsar Bangalore Chennai Dehradun Faridabad Gurgaon Jaipur Kangra Kolkata Mohali Moradabad Mumbai Mysore New Delhi Noida Raipur

Dermatology Diabetology Endocrinology ENT Foetal Medicine General Medicine General Surgery Gynaecology & Obstetrics (Women Care) Haematology Holistic Medicine Infertility Internal Medicine Neonatology Neuroradiology Nuclear Medicine Oncology Ophthalmology Paediatrics Pathology Physiotherapy Plastic & Reconstructive Surgery Podiatry Psychiatry Psychology Pulmonology Radiology Rheumatology Sports Medicine Thoracic Surgery Transfusion Medicine Vascular Surgery

RG Hospital http://www.rghospital.com/aboutus.asp RG Stone Urology & Laparoscopy Hospital Ahinsa Marg, 14-A, Road Khar (West) Mumbai- 400 052 Tel: +91 22 6146 3500 Fax: +91 22 2646 2123 Helpline: +91 93226 53838 F-12, East of Kailash, New Delhi- 110 065 Tel: (011) 4072 1000 Fax: (011) 2621 8743 M S Ramaiah Memorial Hospital New B E L Road, M S Ramaiah Nagar,MSRIT Post, Bangalore - 560 054,Ph: 2360 8888 / 2360 9999,Fax: 080-2218 3276. E-Mail:contact@msrmh.com,http://www.msrmh.com/inter-nationalpatient.php Wockhardt Hospital www.wockhardthospitals.com Medanta Medicity Sector 38, Gurgaon 122001.

India's largest chain of Super Specialty Urology Institutes.Worlds largest chain of Urology Hospital. Guinness World Record holder for treating kidney stone of 13 cm. Only institute to attain ISO 9001:2000 certificate for Lithotripsy, Endourology, Holmium Laser, Laparoscopic Surgeries and Diagnostics.

Interventional Cardiology & Cardiothoracic Surgery, Laparoscopic/ Endoscopic procedures, Gynecology& Obstetrics, Orthopedic surgery with Joint Replacement, General Medicine, Neurology, Nephrology (Including Dialysis), Gastroenterology Neurosurgery, Paediatrics,

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Max Super Speciality Hospital (A Unit of Balaji Medical & Diagnostic Research Centre), 108-A, Indraprastha Extension, Patparganj, Delhi 110092 11 Units in Delhi, Gurgaon and Mohali

Urology, General Surgery,ENT, Dental, Eye and Cancer (surgery, Chemotherapy & Radiotherapy) and diagnostics General Medicine, General Surgery, OBS & Gynae, Paediatrics, Orthopedics Including Joint Replacement, Cardiology & Cardiothoracic Surgery, Urology, Nephrology, Dialysis, Neurology, Neuro Surgery, Dental, ENT, Eye,, Laboratory & Imaging Services, Medical Surgical & Radiation Oncology

List of few more Hospitals for medical tourist in India Tata Memorial Hospital All India Institute of Speech and Hearing Asian Heart Institute Hinduja Hospital Nanavati Hospital Lilavati Hospital Christian Medical College and Hospital, Vellore Breach Candy Hospital World Laparoscopy Hospital,Gurgaon Birla Institute of Medical Research Centre

Medical Tourism Facilitators in India

Bonanza Meditourhttp://www.bonanzameditour.com/ www.imtca.com(Indian Medical Tourism Conference & Alliance) http://www.medicalindiatourism.com/about-us.html Indian Medical Travel Association(IMTA)-http://www.indianmedicaltravelassociation.com/About-Us.php Prime India-http://health-tourism-india.com/ The Meditour-http://www.themeditour.com Affordable Medical Tourism-http://www.affordablemedicaltourism.com/ Akshar Health Care Pvt. Ltd-http://aksharmeditour.com Modi Healthcare And Tourism Corporation-http://www.mhctc.com Uni Health Consultancy Private Limited-http://www.unihealthonline.com Well care Travel Services- http://www.wellcaretravelservices.com/ Firstcare Medicare Private Limited-http://www.firstcareindia.com Nirmal Hospitalities-www.nirmalhospitalities.com India Medi Plus - http://www.indiamediplus.com/index.html Aastha Health Care (Hospital)- http://www.aasthahealthcare.com/medicaltour.html#Idontknowanyoneinindia Meditrips India-http://www.meditripsindia.com/aboutus.html Gawai Consortium, www.gawaiconsortium.com Radiant Medical Travel Services-http://www.radiantmedicaltourism.com/ ITL World Travel Management Company-http://www.itlworldtravel.com/medical-tourism.php Care Medical Tourism-http://www.caremedicaltourism.com/ Indian Medical Holidays-http://www.indianmedicalholiday.com/ (A unit of SKN consultants private limited)(Hospital)

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References : http://www.patientsbeyondborders.com/medical-tourism-statistics-facts http://www.medscape.com/viewarticle/736214 http://www.transparencymarketresearch.com/medical-tourism.html http://www.warc.com/LatestNews/News/Health%20and%20wellness%20market%20to%20boom.ne ws?ID=29914 http://www.busop1.com/wellness.html http://career.webindia123.com/career/options/travel_tourism/medical_tourism/intro.htm http://www.medicaltourismassociation.com/en/certified-international-patient-specialist.html http://www.medicaltourismmag.com/article/cultural-linguistic-competency-and-medical-tourism-sbottom-line.html A study of problems and challenges faced by medical tourists visiting India -A report2011 www.ncbi.nlm.nih.gov Journal List MedGenMed v.9(4); 2007 www.oecd.org/els/health-systems/48723982.pdf

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CHAPTER 6 LATEST DEVELOPMENTS IN MEDICAL TOURISM INDUSTRY IN INDIA (REPORTS FROM INDIAN NEWS AGENCY)
Weak rupee spurs medical tourism in India: Assocham Study (Sep 13, 2013)
NEW DELHI: In view of the falling rupee against foreign currencies, the number of medical tourists coming to India has jumped by 40 per cent in the past six months, according to an Assocham study. "Fall of rupee versus dollar has proved to be advantageous to the patients from Middle East, Africa and SAARC countries to the extent of 35 to 45 per cent on complex surgeries," Assocham Secretary General D S Rawat said. Consequently, the inflow of patients has also gone up by 40 per cent during the last six months, the study showed. The current market size of the Indian medical tourism sector is Rs 7,500 crore and likely to touch Rs 12,000 crore by 2015 with an annual growth rate of 25 per cent. States like Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Maharashtra and New Delhi are fast emerging as India's best medical centres with several hospitals and specialty clinics coming up in the cities, as per the study. A medical procedure that cost a medical tourist USD 10,000 in 2010 would now cost around USD 7,000. An Australian having the same procedure would also pay 45 per cent less today. Similarly, anyone paying in Euros would save around 25 to 35 per cent in the current scenario, the study said. "The inflow of medical tourists in India is also likely to cross 45 lakh by 2015 from the current level of 25 lakh," the study found.

India to remain on top in medical tourism: Top expert

India will remain on top in medical tourism for at least a decade despite attempts from countries like China and Japan to tap into the flourishing business as Indian hospitals have English language and skilled manpower advantages, a leading Indian cardiac surgeon has said. "India's biggest advantage is the language and human technology which cannot be easily replaced", Dr K M Cherian, who is a regular invitee of the Chinese government to address the medical faculties of hospitals as well as to operate in different facilities, told PTI here. India, which made strong forays into global medical tourism with its well established corporate hospitals would retain its top position at least for a decade, Cherian said, referring to efforts by China and Japan to break into the lucrative business. "They cannot do it for the next 10 years. Having equipment and hospitals is not enough. The main problem for them is the language", the 71-year-old Chennai-based doctor said, highlighting that India's main advantage was the English language. Also the Indian medical expertise is turning out to be the soft power of the country, he said. "They (countries like China and Japan) have technology but human technology is missing. That is where we make a difference. Indian doctors are well accepted all over the world," Cherian said. 74

Besides performing the first coronary artery bypass surgery in India in 1975 and country's second heart transplant, Cherian also conducted the first infant cardiac surgery and the first heart and lung transplant. He is also a pioneer in surgeries using tissue engineered conduits, autologous stem cells in heart diseases. Cherian who performed surgeries all over the world has visited China five times in the last few years. He performed surgeries along with fellow Chinese doctors in three hospitals, including a military hospital of the People's Liberation Army (PLA). Right now China only has government hospitals. However much they are good, they cannot serve over 1.4 billion people.

Stricter visa rules driving away medical tourism from India (15 August 2013)
Prathap C Reddy, the cardiologist who built the Apollo Hospitals chain valued at $2 billion over three decades in India, says he's seeking growth overseas as the visa policies drive medical tourists to rivals. Apollo Hospitals is considering hospitals in Indonesia, Cambodia and Tanzania, Reddy said in an interview at his Chennai office. Growth in the number of visitors seeking treatment for heart ailments, cancer and orthopaedic surgery is falling short of Reddy's estimates as India's special visa for patients forces them to visit an immigration office, he said India, which offers the world's biggest savings for US medical tourists, is losing clients to Singapore and Thailand as visa rules and greater awareness of drug-resistant germs that spread from the country scare away patients. Government neglect means India may fail to tap the $40 billion market that's expanding 25% a year, said Josef Woodman, founder of the guidebook Patients Beyond Borders. "They've done everything to ruin our prospects of becoming a medical tourism centre," Reddy said. "I once said India should become the global healthcare destination now I'm swallowing those words. It could grow 10-fold in the next five years, if only the government would facilitate it, the way others have." Apollo forecasts the number of overseas patients seeking treatment at its hospitals in India will increase by about 23% to 80,000 in the year ending March 31. India attracted as many as 350,000 medical tourists in 2012 compared with 250,000 a year earlier, according to Patients Beyond Borders. Thailand treated as many as 1.2 million overseas patients last year, while Singapore had 610,000 medical visitors, according to the guide. Fortis Healthcare set up a hospital in Singapore last year, and in 2009 bought a stake in a hospital in Mauritius. Apollo too has hospitals in Mauritius and Bangladesh. "India has been fairly neglectful of this industry," said Woodman "It makes a lot of sense and Indian hospitals like Apollo and Fortis are wellpositioned to seek a foothold in parts of the world where people have no access to quality care." Apollo and its competitors are also expanding into developed markets to tap patients who are looking for treatment at a lower price. Bangalore-based cardiologist and businessman Devi Shetty has expanded his Narayana hospital chain to the Cayman Islands, where he will open a 140-bed cardiac surgery centre early next year. US patients can save 65-90% by seeking treatment in India ranging from a coronary artery bypass to rhinoplasty, according to Woodman. The average cost of a hip replacement in India, which has emerged as a "thrift" destination for orthopedics and cardiac surgery, is one-fourth of that in the US, he said. Medical tourism to India will increase if the nation allows faster clearance for patients through immigration points, and guarantees the processing of medical visas within 24 hours, said Vishal Bali, group chief executive 75

officer of Fortis Healthcare, in an interview. Gurgaon-based Fortis sees about 11,000 international patients a year, Bali said, compared with 65,000 at Apollo in the year ended March. "India has great potential to be a big player in global health care," Bali said. "India is the hub of our entire health-care delivery system" with the company using hospitals in India to serve patients from South Asia, Middle East and the West, and Singapore to treat patients from Southeast Asia, he said. Did the Visa Help? India in 2005 introduced a special visa for medical tourists, to bolster the industry. However, restrictions imposed by the visa have made it harder for them to enter the country for medical treatment, Reddy said. The visa, valid for one year, requires patients to register with the Foreigner Regional Registration Office within two weeks of their arrival, a process that is "insulting" and physically taxing for people suffering from serious health problems, Reddy said. The permit allows three entries, making it harder for doctors to provide follow-up treatment and deal with complications, he said. The medical visa is also costlier than a tourist visa and isn't available in nations in Africa, which accounts for a majority of the patients seeking treatment in India, according to an Indian Institute of Tourism and Travel Management report. The rules mean "India is losing these patients to Thailand," the report said. V Vumlunmang, a joint secretary in the ministry of home affairs, didn't respond to e-mails and phone calls to his office, seeking comment. Superbug Scare The medical journal Lancet three years ago reported the spread of a superbug with a gene dubbed NDM-1, short for New Delhi etallo-beta-lactamase-1, a reference to the city where a Swedish man was hospitalised with an infection that resisted standard antibiotic treatments. Reddy said concerns about drug-resistant bugs were excessive. The market for medical tourism in India will grow at an annual rate of 30% to Rs 95 billion ($1.55 billion) by 2015, according to the Associated Chambers of Commerce and Industry of India. Thailand earned 31.12 billion baht ($995 million) in the year ended March 31, according to the Tourism Authority of Thailand. "Medical tourism became a priority for Thailand and Singapore," said Fortis' Bali. "Both have sort of taken on that opportunity at the highest levels within the country, because they felt there was an economic upside for them by supporting this trend. We haven't really taken it on as a national priority."

Chennai remains favourite destination of medical tourists (April 20, 2013)

Chennai attracts about 40% of the country's medical tourists and more than six lakh tourists visit the state every year, according to a study by Confederation of Indian Industries (CII). The inflow of medical tourists to India has increased by 23%, with Chennai continuing to be the favourite destination, said CII officials. The city receives up to 200 foreign patients every day owing to the quality of healthcare, said S Chandrakumar, convener of the CII healthcare panel, at the international conference and exhibition on health tourism in Chennai Trade Centre on Friday. Around 8.5 lakh tourists visited India in 2011 for treatment. Last year, it increased to 1.1 million, said Chandrakumar. Through the two-day expo, CII and Tamil Nadu Tourism Development Corporation hope to give a fillip to Tamil Nadu as a preferred medical tourism destination. The state produces the maximum number of doctors and paramedics in the country, said health secretary Dr J Radhakrishnan. "Many tourists from the Middle-east, Africa, South and South east Asia come to Tamil Nadu every year," he said. He said the government plans to build a 'medicity' with public-private partnership under the vision 2023 programme, which will expand the scope of medical tourism in the state. 76

Government support and accreditation of both hospitals and alternative medical practices could make the state the most sought-after destination for health tourism, said delegates at the meet. "There is no uniform policy for health tourism across medical institutions. If medical tourists have less stringent visa norms, it will be a boost to the sector," said Srinidhi Chidambaram, vice-president of the Apollo Hospitals Group.

TN is the most preferred medical tourism destination for Omanis, Indian envoy says (August 20, 2013)
Tamil Nadu is the most preferred destination for Omanis visiting India for treatment, according to Indian ambassador to Oman J S Mukul. Mukul, who called on governor K Rosaiah here on Tuesday, said many Indian companies had entered into joint ventures with Omanis firms in sectors like pharmaceuticals, fertilizers, energy and engineering. He said there were about 1,500 Indian companies in Oman. He said Oman was one of the most developed and politically stable Arab nations and shared a cultural and commercial link with India dating back to the period of the Indus Valley civilization. There were about seven lakh Indians in Oman and an Indian Community Welfare Fund had been instituted to help the poor and needy immigrants, he added.

Goa to promote health-and-wellness tourism (August 19, 2013)

Goa needs more high-end hotel rooms to hope for big-ticket tourists, says a draft investment policy prepared by a government-appointed task force that says the state can position itself as a health and wellness tourism destination. The Goa Investment Policy 2013 that has just been put into the public domain for suggestions has also outlined the importance of medical tourism in taking forward Goa's story. "The government targets granting permissions to starred hotels, across categories, to a cumulative additional capacity of around 8,000 beds in the next five years," says the policy, authored by a task force headed by Atul Pai Kane, the Goa chairman of the Confederation of Indian industry (CII). The report also says that attracting high-end visitors will also mean creation of infrastructure and facilities which in turn will provide gainful employment for the state's youth. The current disparity in the proportion of low-end to high-end hotels will be made up by encouraging more boutique and luxury hotels in the state, the draft policy says. The increased focus on high-end tourists also comes with the inevitable requirement of creating high-value tourism products, which should include oceanariums, theme parks, shopping malls, entertainment centres, high-end water sports and adventure sports, the policy says. At present Goa attracts nearly 2.8 million tourists annually, out of which over half a million are foreigners. Setting its sights on the emerging segment of health and wellness tourism, which attracted over 1.3 million people to India in 2013 alone, the draft policy suggests that Goa has "good basic healthcare infrastructure" to cater to the segment. But more needs to be done, the draft policy says. "While medical tourism is growing in Goa, the government is keen to attract investments in new facilities and draw more medical tourists to Goa for high-end and complicated procedures. For medical tourism to take off in a big way, uniformity and quality of services offered are critical," the report says, recommending several steps which the Goa government could take to beef itself up in the medical tourism sector. The recommendations include setting up of large healthcare facilities to meet the needs of increasing medical tourists, mandatory registration with the Directorate of Health Services and the Goa Medical Council for facilities offering medical tourism and a rate card and details of facilities to be offered. 77

Also meted is a government portal with details of each healthcare facility and which will serve as a liaison between patients and doctors and medical facilities.

Medical tourism counter proposed at airport (JUN 10,2013)

AHMEDABAD: The Airport Authority of India (AAI) has issued a tender for opening a medical tourism counter - a first of its kind - at the Sardar Vallabhbhai Patel International Airport to facilitate the international tourists get the best medical care in the city. "The aim is to improve facilities for passenger and not to earn money," said R K Singh, airport director. AAI will provide 10 sq m of space at the arrival area of the international terminal to the highest bidder. The space will be provided at Rs 3,500/sq m/month which is much less than what AAI charges for other counters like food and hotels. "We usually charge Rs 6,500/sq m/month but for medical tourism counter, we are offering a subsidized rate," said Singh. The counter is aimed at providing the necessary information regarding the procedures, monetary transaction and international code of treatment. On being asked why will patients come to medical tourism counter at airport when they already have a tie-up with the hospital concerned, Singh said, "People always seek better facilities. The counter will help them find the best option available for them." "If you go to a hospital, you will have to wait for your turn for long. The plan aims to do away with this waiting time. AAI has consulted with Apollo Hospitals, Shalby Hospitals and Vasan eye care for the medical tourism counter," he added. Ahmedabad being one of the fastest growing cities is aspiring to be one of the best healthcare providers in the state as well as India. The growth of 33 per cent has been registered in the number of medical tourists in the state while the country has registered growth of 20 per cent. The city hospitals are seen as hot destination for medical tourism from all over the world. This has pushed the city hospitals to upgrade their technology, infrastructure and bring them to the level of developed countries.

Gujarat potential market for ayurveda-based tourism (January 18, 2013)

Gujrat which is doing well in medical tourism has good potential for Ayurveda-based medical tourism said members of the Mission Ayurveda, Rajkot on Friday. The mission is working for development of ayurvedic medicine in India. Gujarat is the first state in India that start ayurveda university. Now it is time to explore other possibili ties to develop and popularise ayurveda," said Gaurang Joshi, organizing secretary, Mission Ayurveda, Rajkot. "Ayurveda based medical tourism is still an untouched area where Gujarat has good potential and many things can be explored," Joshi said. He said that on behalf of the mission he and his team would be soon meeting chief minister Narendra Modi to discuss ayurveda-based medical tourism in the state. They are also preparing a draft paper in this regard. Explaining the importance of ayurveda based tourism Joshi said, Panchkarma treatment is becoming popular in Gujarat and India. So many people from abroad also come here for panchkarma treatment and we have to develop such policy which can increase ayurveda tourism in Gujarat,Joshi said. According to him more and more people are shifting to ayurveda but they face big problem of raw material. Due to lack of awareness and decline in natural forest cover area, availability of raw material has decreased, he added. Dhirendra Joshi, president of Mission Ayurveda said, India need separate drug control authority for ayurveda. While many things are being done in countries like America and Europe with regard to ayurveda based treatment and research, but in India nothing was being done.He also felt that there was need to organise the sector. Giving details of the international ayurveda conference Raj Ayu Con 2013 to be held in February, Joshi said that they were considering to form national level association for ayurveda during the event. 78

The conference will include 28 national and international speakers, while 120 research papers on Ayurveda, Homeopathy and Unani comprising diversified segments will be presented during the event. Approximately 150 international delegates from USA, UK, Canada, Germany, The Netherlands, Sri Lanka, Nepal, Israel and Brazil will participated in the event. While approximately 900 delegates from India will participate from across states.

Medical tourism picking up in S Gujarat

SURAT: Dr Harshad Joshi, a knee replacement surgeon, would be performing nearly 200 surgeries during November-December. Around 70 per cent of his patients who would be operated upon during this period are non-resident Gujaratis (NRGs) from the USA, the UK, South Africa, Australia and New Zealand. Specialized and planned surgeries have become a lucrative business for the city doctors. Also medical tourism is picking up in south Gujarat. Five years ago, just 10 per cent of NRGs from south Gujarat used to plan medical treatment to coincide with visit to their native places. Now, this percentage has gone up to 60 per cent, medical fraternity sources said. In south Gujarat, the peak months for the NRG visit are November, December, January and February. It is during this period that the doctors work overtime to attend to the huge number of patients coming for ophthalmology, knee and joint replacements and spine surgeries. "A simple Lasik treatment that costs $ 3,000 abroad can be done here for Rs 25,000. With falling rupee, it is not only affordable but more than affordable for the NRGs," said Dr Paresh Vaidya, ophthalmologist. A simple knee-joint implant is available for Rs 90,000 in India as against $80000 in foreign countries. As a result, many NRG patients, who are without insurance in the USA and the UK, pre-plan their treatment during the visit to their home towns in India. Dr Harshad Joshi, a knee-replacement expert, told TOI, "The treatment here is affordable. It is a huge saving for the NRGs. We have started receiving bookings from NRIs in South Africa and the UK." Cervical disc surgery is done in Surat for Rs 1.5 lakh. But, it costs nothing less than $10,000 abroad. "The cases of NRGs coming to India for spinal surgeries have gone up. It is not as big compared to kneereplacement or eye surgery cases, but there has been a steady 10 per cent increase year-on-year basis," said Dr KC Jain, a neuro-surgeon.

For visitors to Kerala, it's a golden rendezvous

KOCHI: Tourists, international and domestic, who come to Kerala spend huge amounts of money on purchase of gems and jewellery. According to a first of its kind study commissioned in two tourist states of Kerala and Madhya Pradesh by the Ministry of Tourism, India, to understand purchases made by visitors and industries benefited by these purchases, the tourist expenditure on gems and jewellery in the state was Rs 1,04,283 lakh, during 2009-10 period. This is almost half the amount of money tourists spend on accommodation and hotel services and much higher than the amount spend on health and medical related services in Kerala, which promotes medical tourism in a big way. The study titled Regional Tourism Satellite Account for Kerala and Madhya Pradesh and conducted by National Council of Applied Economic Research (NCAER), Delhi, relied on tourist arrival figures of 20092010 as well as household surveys. The report was submitted recently to the ministry. Total internal tourism expenditure on accommodation services and hotels during the period was Rs 3,52,005 lakh, while they spend Rs 1,76,171 lakh on food and beverages in restaurants. The amount spend on health and medical related services was Rs 67,166 lakh. The data on total internal tourism consumption by products incurred by tourists, both domestic and international, on gems and jewellery in Kerala is Rs 1,04,283 lakh, of which Rs 92,000 lakh was by international tourists. The amount spent by NRIs on purchase of gems and jewellery was Rs 37,503 lakh. Of this Rs 8,743 lakh was by persons of Indian origin (PIO) while Rs 45,754 lakh was incurred by others. 79

TSA provides information on purchases made by visitor and industries which are benefited by these purchases, characteristics of visitors and visits and employment and investment profile. Tourism expenditure is the "amount paid for the acquisition of consumption goods and services as well as valuables, for own use or to give away for and during tourism trips". Confirming the trend, Kerala Jewellers' Federation president, Kalyana Raman said, "In a day, 10% of the customers who make purchases in our shop are tourists. The traditionally designed jewellery is a major attraction for them. Some even like the light weight ornaments". "Shopping is an integral part of tourism activity in the state. A major tourism product we have on offer is a blend of traditional and heritage jewellery as well as modern designs. Also these products are marketed well internationally, leading to curiosity amongst tourists to purchase the product", added president of Confederation of Tourism Industry, Kerala, E M Najeeb. ## Kochi: Tourists, international and domestic, who come to Kerala spend huge amount on purchase of gems and jewellery annually. In a first of its kind study commissioned in two tourist states of Kerala and Madhya Pradesh by the Ministry of Tourism, India, to understand purchases made by visitors and industries affected by these purchases, reveals that the tourist expenditure on gems and jewellery in the state is almost Rs 104283 lakh. This is almost half of the money spend on accommodation services and hotels and much higher than the amount spend on health and medical related services in Kerala, which promotes medical tourism in a big way. Total internal tourism expenditure on accommodation services and hotels is Rs 352005 lakh, followed by Rs 176171 lakh on food and beverages in restaurants. The amount spend on health and medical related services was Rs 67166 lakh

Rajasthan moots plan to boost medical tourism Jul 4, 2012

JAIPUR: Rajasthan will soon attract patients from neighbouring countries as it is set to announce better healthcare packages for foreign nationals as part of its medical tourism package. For the purpose, the state government has started working on formulating a separate policy on medical tourism. The idea of the policy, in its initial stage now, has been conceived by the state medical health and family welfare department recently. "Provisions will be made in the policy to offer health packages for patients coming from neighbouring countries. Obviously, we are not targeting to attract patients from the West and other developed countries. But through this policy, we will offer better healthcare services to the patients coming from the neighboring countries like Bangladesh, Nepal, Afghanistan and other neighbouring countries. The policy is in the initial stage, it will take some time to implement the policy," minister of state for health Rajkumar Sharma said. Besides, the state government has plans to tap growing the tourist activities in religious places, including Ajmer dargah. Since a lot of tourists from neighbouring countries come to the Ajmer dargah every year, the department has an aim to offer lucrative treatment packages to the foreign tourists. The department officials claimed that because of the free-medicine scheme, patients from neighbouring states have increased. Now the state government is targeting patients, who require 'terminal care' from the neighbouring states. But it remains to be seen how the state government takes it up or it will take help of private hospitals in the policy, which have spawned in the city in large numbers. The state government is also helping private hospitals by allotting land on concessional rates or by allowing them set-up on public private partnership (PPP) basis. Manas Arogya Sadan Heartcare & Multi-specialty Hospital, which will run on a PPP basis with Metro Institute of Medical Sciences Private Limited for a period of 30 years, is expected to become operational from September 2012. Besides, state government confirmed that Bombay Hospital would also come up in Jaipur as its land allotment process by the Jaipur Development Authority is in the final stages.

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Private Hospitals and Nursing Homes' Society president in Jaipur, Dr Sanjay Arya, said, "The government is allowing big private hospitals to enter Jaipur by offering land on concessional rates. These hospitals are mainly terminal care hospitals. But the government should also make better rules to boost the hospitals which are small and catering general patients in large numbers."

Panchkarma of Banaras Hindu University to promote medical tourism (Jul 1, 2012)

VARANASI: The revamped Panchkarma division under the Department of Kayachikitsa, Faculty of Ayurveda in Banaras Hindu University is all set to bolster medical tourism in the city, which is believed to be home of Ayurveda greats like Sushruta and Charak. While BHU V-C, Dr Lalji Singh would unveil the revamped Panchkarma centre on Sunday (July 01), the centre is gearing to provide healing touch to number of patients from near and far away places in the country and abroad. It may be mentioned here that Institute of Medical Sciences (IMS), BHU has signed an agreement with Kerala based Ayurvedic company to extend expertise in the field of manufacture of ayurvedic drugs and Faculty of Ayurveda, BHU would ensure monitoring under public private partnership (PPP) model. While over three-decade-old division (established in 1980) is witnessing collaboration with Kerala Ayurvedic Ltd (a century-old Kochin-based pioneering Ayurveda centre that has over 40 international ayurvedic outlets in the world), the move is promising to expand the potential of one of the oldest components of medical system besides paving the way for garnering revenue through medical tourism in the city, which is already one of the favorite destinations for domestic and foreign tourists. According to Prof TM Mohapatra, director, IMS, BHU, the agreement has already witnessed infrastructural development at Panchkarma unit under the Faculty of Ayurveda. He also emphasized that initiative would ensure availability of quality raw materials and processed materials to come up with quality ayurvedic medicines in the region. It is also worth mentioning that Kerala has already emerged as major centre for medical tourism, attracting a large number of foreign and domestic visitors to the state. The field has made significant contribution for promoting tourism potential in the region with specialization in Panchkarma and other practices of Ayurveda. As per Prof SK Tiwari, head, Department of Kayachikitsa and co-ordinator, Panchkarma division, BHU, the age-old practices involved in Panchkarma have already attracted a number of chronic patients across the country to the centre and the collaboration with Kerala company would definitely bolster the potential of the discipline with attractive packaging. The practice promises to provide respite from chronic pain including cancer and disc-prolapse and better packaging and facilities at the centre would attract even foreign visitors and patients, making it a truly global centre for medical tourism, he added.As per reports from the department, the unit has made rapid strides in the age-old practices of Panchakarma, carving a niche in different methods and techniques practiced by Ayurveda greats like Sushruta and Charak. Now, cases of chronic pain including disc prolapse, cervical spondylitis, lumbar pain, arthritis, elephantiasis and others are successfully treated with Panchakarma. Apart from patients from neighbouring regions including East UP, Bihar, MP, Chhattisgarh, a number of patients from West UP and Delhi also visit the unit. Some of the special treatment methods offered at the unit include Agnikarma (shalaka treatment) involves precise touch of red hot metal tube (pointed at one end) at specific points to give relief from pain. Besides, leaves of Aloevera and Trifala are also used to provide instant relief in superficial burn. Conditions like arthritis, spondylitis, filaria, sciatica and muscular spasm are also treated using Agnikarma.Similarly, special methods including kativasti that witness placing of lukewarm medicated oil in metallic pan over the body that is fixed in a mixture of wheat and gram flour, is also used for treating disc prolapse, muscular spasm and ligament injury. Other practices including Nariswedan that involves treatment with vapours of medicated decoction passed through tubular pipe also provides respite from chronic pain.

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 Translators aid medical tourism (March 25, 2012)

If words are the physicians of the diseased mind, the words spoken by these physicians are helping heal not only the mind but also the body. With an increasing numbers of patients coming to Noida - a fast emerging hotspot for medical tourism - hospitals in the city have hired translators to make these patients feel comfortable during their treatment while at the same time helping in the facilitation of their treatment. Doctors said a bulk of their international patients is coming from Balkan and African countries in search of quality and affordable treatment for a variety of diseases. "The problem is there is a genuine difficulty in communication which can prove to be a hindrance in case of diagnosing these patients. However, we have employed translators with fluency in a variety of languages to solve the problem. It not only makes the patient feel at home but also helps the doctor," said the Fortis Noida spokesperson. Recently, Kailash Hospital in Noida successfully treated 11-year-old Shohona Ezhnazarova from Tajikistan. Doctors said the miraculous surgery cured the girl from a rare heart condition that had restricted her movements and growth. All this wouldn't have been possible without the help of doctors proficient in Russian. "Language can become an unfortunate barrier in case of such international patients. In the case of Shohona, we were lucky to have Dr Tauseef Akhtar who is fluent in Russian and had helped us in communicating with the patient and her family. He also helped us in translating her previous medical history for a better understanding," said the spokesperson of Kailash Hospital.Students studying different languages are increasingly turning to medical tourism as an avenue to utilize their skills. "I am presently studying Russian and also plan to study Croatian and Bulagarian languages. With the increasing price tags of medical surgeries in the West, patients are turning to India for treatment," said Shreyas Tyagi, a student of the Department of Slavonic and Finno-Ugrian Studies. References http://articles.economictimes.indiatimes.com/2013-09-13/news/42041894_1_assocham-studymedical-tourism-weak-rupee http://www.deccanherald.com/content/336303/india-remain-top-medical-tourism.html articles.economictimes.indiatimes.com Collections Visa articles.timesofindia.indiatimes.com Collections Cii articles.timesofindia.indiatimes.com Collections Medical Tourism http://www.business-standard.com/article/economy-policy/gujarat-potential-market-for-ayurvedabased-tourism-113011800070 articles.timesofindia.indiatimes.com Collections Medical Tourism articles.timesofindia.indiatimes.com Collections Medical Tourism articles.timesofindia.indiatimes.com Collections Ayurveda articles.timesofindia.indiatimes.com Collections

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CHAPTER-7 MEDICAL TOURIST VISITING INDIA: PROSPECTS AND CHALLENGES

Medical tourism is a term referring to the people traveling to other countries to obtain medical care. Like any other rapid growing industry, medical tourism has prompted ethical and legal issues. These issues are mainly pertained to malpractice and consumer protection. Beside these, risk management, foreign hospital liabilities, international advocacy, facility ownership, intellectual property, organ trafficking and ethical issues are other matters that should be addressed. Travel medicine also contains alternative medicine and telemedicine. Therefore, comprehensive and detailed legal regulations should be performed to govern mentioned issues. Otherwise, in future this industry will face serious challenges. Medical tourism is an opportunity for healthcare facilities to benefit from international patient market. To gain this goal, they must first attract foreign patients; therefore healthcare providers should consider leveraging on both clinical and business considerations. Well-coordinated efforts facilitate the process of traveling, hospitality, and the healthcare trade may lead to a sustainable growth of this business. Medical tourism has several feathers. Ethical and legal issues are one of them.

Legal &Ethical Issues This aspect of medical travel is more important. Medical travel has raised numerous ethical concerns. For example, it may lead to a duality in health care policies: ensuring the access of health care for every citizen, while on the other hand promoting state-of-the-art technologies for foreign patients. Others have raised concerns about possible changes in doctorpatient relationships, by commoditization of health care services. Most prominently, medical travel involving human body resources, especially organs, has raised comprehensive debates including concerns both on how they are obtained and how they are used. Consider this fact; many countries have set restrictive policies governing their donation and access. But international variations in such legislation have encouraged some patients or health care providers to take advantage of those differences. In some countries human body resources are more available, because underprivileged and vulnerable populations of these countries jeopardize their personal health for a small financial reward. It is also noticeable that in some of these countries standards of health care for donors are often poor and lacking follow-up cares. On the other hand, every country has different standards, rules and regulations that have limited the cross border delivery and seeking of medical care. Since different standards exist between the international tourist and the destination country, many challenges face the legal profession. Presently the internationally accepted policies to settle medical tourism issues and debates regarding to malpractice across international boundaries is limited. Patients may not be covered by personal insurance or be incapable to seek compensation by undesirable treatment. Ethical issues commonly involve organ 83

transplant, stem cell research and that of the doctor and patient relationship. Additional legal issues involve alternative medicine and telemedicine. Policy Issues in Medical Travel One of the most important problems in medical travel is follow-up. In some cases for procedures requiring aftercare to monitor the healing process or remove stitches, traveling patient have problems finding a local physician willing to provide postoperative follow-up care. Faithlessness to another providers work is one reason some physicians are not willing to provide follow -up care to patients treated abroad. Another reason for this loath is that patients treated abroad often lack insurance, since many doctors assume that health insurance is the only way for patients to finance medical care. Although in some patients their regular doctors continue to treat them throughout recovery. Patients with a regular physician will likely fare better than those who are seeking physician care for only a shortterm (postoperative) need. Cross Border Issues A medical tourist should be well aware of possible complications and legal issues that he may face across the international borders. In all medical and surgical interventions potential risks lies, no matter the patient is being treated in his home country or abroad and independent to the proficiency of the practitioner. Still the legal implications are undefined when the patient undergoes his medical care abroad. The participants in the legal issues include the client, facilitator agent, employer, and destination provider. Today there are limited regulatory policies for medical tourism. The hospital care administrator needs to aware that the international patients may be protected by laws of their home country unlike the local patients. Hence there may be need to appropriately address the legal conflicts. For example Malaysia is becoming one of the biggest markets for medical tourism in Asia. The rise of this Medical Tourism phenomenon is due to combination of medical travel with visiting popular tourist destinations in Malaysia. Presently, the excessive number of foreign patients has made the Malaysian health care providers topic of numerous malpractice claims. Language barriers, unsatisfactory provision of treatment and maintenance of high-quality treatment are some of the problems that patients and health care providers are facing. Forgione, Smith and Weiner have studied some of the issues facing lawmakers, health service policy makers, and health service researchers regarding the impact of medical tourism on the US health care system. Many Americans travel across the border to receive cheaper treatments such as cosmetic, dental and plastic surgeries, with the need for less stringent laws which benefits global health care. As an example, legislators in Texas may allow health providing organizations to exist on either side of the US/Mexican border. This has created a challenge amongst US physician who cant compete with the much cheaper treatment costs in Mexico and also Mexican legal system that protects the Mexican doctors. Privacy Protection Medical records are necessary for communication between professionals and to maintain continuity of treatment. The sharing of medical records can be difficult while traveling overseas and currently is performed by the medical tourism facilities in the destination country or facilitator agent. The facilitator is usually an agent connecting the patient to the health care organization in the destination country. Therefore the agent is not a provider of health service and is not practicing medicine. The provider is in close contact with patient and has access to the patients records. Hence he must ensure confidentiality and security of medical information. Unfortunately, laws regarding privacy and data transfer in the hosting countries are currently unregulated in medical tourism. The European Union (EU) has a data guidance to protect personal and medical data. The directive prohibits the transfer of data from the EU to a recipient outside of the EU unless the recipient country provides protection that is comparable to the EUs. Only three countries of Switzerland, Canada, and Argentina are recognized to have data protection safeguards consistent with the European Standards. The transfer of data from the European Union to the United States can only be implemented with the patients consent. The United States has a privacy protection in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which protects all health information that is part of an individual medical record or payment 84

and requires the covered entity to keep track of disclosures in print or electronic form. Privacy stipulations require standards to be set to secure and protect electronic information. In certain situation disclosure of the information might be possible, for example Individuals may request personal information through informed consent. Canada has two federal privacy laws, the Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). The Privacy Act applies to Canadian government agencies and places limitations on their ability to collect, use and discloses personal information. PIPEDA applies to the private sector and similarly regulates the collection, use or disclosure of personal information in connection with commercial activities. Malpractice Since laws referring to medical malpractices are widely different in origin and destination countries, policies and strategies need to be set to coordinate these rules to protect patients and health care providers in cases of lawsuit disputes. Consent forms have been developed for this matter. Another strategy could be development of an alternative dispute resolution system. Currently there is no organized International system for resolving legal disputes of medical tourists. A model for developing an International Legal Mediation, Arbitration and Alternative Dispute Resolution system for healthcare can be derived from commercial entities. A number of countries including Australia, France, Japan, Korea, UK, Germany, Russian Federation, The Netherlands, Malaysia, Denmark and India have entered into bilateral investment treaties. These agreements allow the settlement of disputes between an investor of one contracting party and an investor of the other contracting party through negotiation, conciliation and arbitration. However, some differences can be only settled by civil suites such as matters of public rights, proceedings under the Foreign Exchange Management Act (FEMA), intellectual property rights, taxation matters, winding up under the companies act, and insolvency proceedings. Overview of Legal and Ethical Issues in Medical Tourism. 1. Legal Expectations by Medical Tourists. 2. Regulations and their Implications. Global Federated Local 3. International Legal Mediation, Arbitration and Alternative Dispute Resolution System. A System with Fixed Rates of Compensation, including Caps. 4. Liabilities of Destination Provider. 5. Risk and Liability for Medical Travel Agents Medical Travel Insurance Facilitators Medical Air Transports Hotels and Resorts Medical Services Medical Healthcare workers 6. Legal aspects/liabilities for Advertising and Marketing. Legal limitations on international healthcare marketing 7. Legal aspects for Information Mechanism on Global Health 8. Future Implications for Regulators, Quality Control and Compliance Organization. 9. International Advisory Services. 10. Accreditation Potential Impact on Patients Engaged in Medical Tourism

Patients usually have no idea about the potential for infectious and noninfectious complications from medical tourism, and there is little reliable data available regarding destination countries. Patients rarely understand the tradeoff between saving money on medical expenses and obtaining potentially life-prolonging medical care that the patient could otherwise not afford, and sacrificing 85

potential legal remedies should medical negligence occur. Currently, there are no reliable, comprehensive sources for patients to learn about legal recourse for malpractice committed in [foreign] jurisdictions.

There is a lack of governmental safeguards ensuring the quality of healthcare generally and the safety and effectiveness of certain procedures specifically. There is also no international governmental body for accrediting hospitals, physicians or other health professionals. Standards may vary widely from country to country and even within countries. Foreign physicians may promise to provide follow-up care to medical tourists using telemedicine, but there are serious limitations in the consistency of law and regulations governing the practice of telemedicine in foreign countries.

Potential Impact on Tourists Home Countries and Their Health Systems

Patients may be offered procedures and techniques in foreign countries that are illegal in the patients home countries (e.g., abortion and euthanasia) or illegal both in their home countries and the destination countries as well (e.g., organ trafficking). Patients may return from medical tourism in foreign countries with serious medical complications that create both an economic and an ethical burden for the physicians in their home countries, even to the degree of causing home country patients to be fatally deprived of an organ transplant when a donor organ went instead to a returning transplant tourist in emergency ne ed of a second transplant surgery. Medical tourism may deprive US hospitals of revenues that they use to cross -subsidize care for the poor. There is an increased risk of a global market of privatized, commercial health care delivery that threatens the future of public healthcare systems. Some observers have speculated about possible political risks in terms of sovereign (foreign policy) relationships if the impact, for example, of medical tourism involving US patients traveling to India [and other countries] was to severely impact the comparative advantage for the US in the hospital business. . . .[cause] a loss of reputation and prestige for the US health care system, and create a possible impact on immigration of foreign doctors to the US (upon whom the US healthcare system depends for primary medical care) if it became attractive to remain in their home countries.

Potential Impact on Healthcare in Destination Countries Governments, and their national ministries of health and trade, have been accused of sacrificing their public health sectors, particularly in terms of access by rural/provincial and indigent populations, in favor of attracting foreign medical tourists with attractive currencies while using public funds to facilitate that tradeoff. Governments have argued that increased revenues from foreign tourists actually strengthen public healthcare, or that hospitals receiving public subsidies must provide a certain percentage of care to the poor and indigent citizens of the host country. Yet these arguments have been challenged in such countries as Cuba, India, the Philippines, Thailand, and those and other countries. Solutions

The sector collectively could choose to maintain the status quo and ignore the ethical and other criticism. If international opinion about the sector changes in the future (say, after the death of a celebrity patient or of a photogenic child), however, then national legislatures, regulators, or accrediting organizations may choose to actby way of law, regulations, or new accrediting standardsto mandate changes of behavior in the sector, and there may be significant reputational damage. A second alternative would be for individual countries or their ISQua-accredited accrediting organizations to take action with regard to health professionals, facilities, and allied businesses engaged in medical tourism within their own jurisdictions. 86

A third alternative scenario would be for individual groups of health professionals, health facilities, and associated businesseseither within individual countries or across national linesto adopt and enforce new standards that addressed these criticismsa form of self-regulation, but one that might not seem credible because it was neither independent nor free of potential conflicts of interest. A fourth alternative might be for an organization such as the Medical Tourism Association or global health organization WHO which provides regulatory guidance health policy frameworks on specific global health issues to form a task force of both interested sector member organizations, clinician and patient advocates, and outside expert resources unaffiliated with the sector to facilitate what has been called a transparent ethics engagement mechanism with stakeholders. Such a process could yield best practice criteria or ethics guidelines that could be recommended as possible new or revised standards to the International Society for Quality in Health Care and its accredited organizations who would then independently assess the appropriateness of such standards.

Dos and Donts for Smart Medical Tourist 1. Do go where you know youll get excellent medical treatment. Many medical tourism companies promote countries or hospitals they have very little information about. When choosing a medical tourism company or agent, make sure the hospitals these companies are promoting actually work with the company or agent. You can ask the hospital for a list of the medical tourism companies they accept. When major countries promote themselves as medical tourism destinations, they may be promoting only a few of the hospitals with the highest medical standards or they may be promoting the country as a whole without heed to the quality differences they are imposing on unwitting medical tourists. Its good to know which it is. 2. Do plan ahead, especially if youll be traveling at peak tourist times.

Competing for treatment with other medical travelers and health tourists, and for hotel space with regular tourists. The most popular times medical tourists choose to go abroad for treatment often coincide with other tourist times. Excellent surgeons dont grow on trees. Ours have full schedules. 3. DONT rely mainly on the Internet for your research.

The best surgeons dont need to solicit business. Hospital web sites are advertising t ools that often contain outdated or incomplete information, especially about staff and costs. Chat rooms, testimonials, patient ratings are additional sources of information found on the Internet.

4.

DO ask about a surgeons fellowships or specialized training.

Does he or she regularly attend international professional meetings? How recently has she practiced or trained in the U.S. or Canada? How many years of experience does he have in the specialty? Medical tourism companies should have this information. If youre working with a certified medical travel concierge, he or she will most certainly have this. 5. DO invest a few dollars in a telephone call. Conversation with the surgeons representative or with your medical travel concierge will be a good indicator of the attention youll get later. All good medical tourism companies will be happy to arrange this for you. 6. DONT cut costs by going with the lowest bidder. Keeping down the cost of surgery or staying at a budget hotel may sound like a good idea at first, but experience shows you may be sorry later. 87

This is especially so with plastic surgery. Plastic surgeons are reluctant to revise another surgeons results so if you make a mistake, you may live with it for a long time. The better solution is to use an experienced medical travel company and a top surgeon. 7. DO get everything (or as much as you can) in writing. Before you go, know your costs, procedures, dates and times of the consultation and surgery, number of nights in the hospital and contact names and telephone numbers your family can use to reach you. 8. DONT take chances. There is always some doctor somewhere who will agree to anything you want. This may be the only time you will travel for medical treatment. Do it right. Medical tourists often have time and work constraints, and want to get things done as quickly as possible. Medical tourism companies rely on the individual medical traveler to take responsibility for aspects of the medical journey. 9. DO use a trained medical travel concierge. Most medical tourism companies have personnel to guide you in making your choices. A good, experienced medical travel advisor has a direct pipeline into the best doctors and hospitals. In the long run, you will save money, get the best treatment, have a stress-free recovery and return home truly relaxed.

References Medical Tourism Raises Ethical Concerns | News | The Harvard Crimson Ethical and legal implications of the risks of medical tourism for patients: a qualitative study of Canadian health and safety representatives perspectives, http://bmjopen.bmj.com/content/3/2/e002302.full.pdf+html http://www.mayoclinic.com/health/travelers-diarrhea/DS00318/DSECTION=prevention http://www.webmd.com/digestive-disorders/features/travelers-diarrhea-what-you-need-to-know http://www.smartraveller.gov.au/tips/health.html http://www.smartraveller.gov.au/tips/travel-smart.html http://travel.gc.ca/travelling/publications/drugs-and-travel http://www.traveldoctor.com.au/files/editor_upload/File/factsheets/9115%20TD%20Health%20Fact %20Sheet%20Bali.pdf http://frugaltraveler.blogs.nytimes.com/2013/01/29/should-you-buy-travel-insurance/?_r=0

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CHAPTER-8

SKILLS REQUIRED IN MEDICAL TOURISM

Medical Tourism (MT) also termed as medical travel, health tourism or global healthcare is the provision of cost effective private medical care in collaboration with the tourism industry for patients abroad who need specialized treatment. Medical tourism - can be defined as the patient traveling from highly developed nations to less developed areas of the world for obtaining medical care due to various reasons, such as better convenience, lower cost, reduced waiting time to undergo a surgery/ treatment, which are unavailable in their own countries. Along with the treatment, they can also enjoy the charm of the countries they are visiting. Medical tourism is not just treating the patients who travel for medical care; it is all about making the patient feel at home away from home. Depending on the location and treatment procedure, a medical vacation can save up to 50%, 30%, or even 10% of what you would pay in your home country. Millions of medical travelers or medical tourists travel overseas for their medical, dental and cosmetic procedures. Medical quality standards and international accreditation vary widely across the globe. As medical tourists may face unknown risks related to quality, safety and ethics, they look for medical / health tourism provider (medical tourism facilitators). A medical tourism provider may be an organisation or a company specialized in certain areas of healthcare. They seek to bring together a prospective patient with a service provider, usually a hospital or a clinic. It is the medical tourism provider who is responsible to offer complete information about medical facilities, quality, safety and legal issues. This include information about the hospitals, clinic, doctors / medical professionals, travel agencies, resorts, medical/ travel insurance overseas as well as information's of local areas. The process of medical tourism begins with a person seeking medical treatment abroad, contacting a medical tourism provider. The patient must provide their medical report, including the nature of ailment, local doctor's opinion, medical history, diagnosis and other additional information. Then medical treatment is advised by certified medical doctors or consultants and the approximate expenditure for the treatment, choice of hospitals and tourist destinations and duration of stay, etc. are discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home. Many people seeking overseas healthcare options will not have any idea about where to start and what to do for their particular needs. The role of medical tourism provider / facilitator commence here. Medical tourism facilitators serve as a bridge between the patient and healthcare provider to ensure the patient has a very positive experience from beginning to end. They play an important role as educators, organizers, advocates etc. for the safe delivery of overseas healthcare individual. The facilitator plans the entire medical trip for an individual - from contracting for flight and hotels to organizing transportation, working with the patient to determine the best destination, coordinating with doctors regarding medical records and setting up calls for them to speak with their healthcare providers etc. As most medical tourists do not speak their native language, the facilitator makes sure that someone at the hospital speaks the patients language, create an efficient system and insulate a patient from any of the language barri ers that might arise. Medical tourism facilitators also plan tourism activities for the patients. Some medical tourism facilitators will request an advance deposit from the medical tourist and ask them to pay the balance at the hospital. Medical tourism which is a blend of leisure together with wellness and healthcare mainly focuses on two kinds of treatment systems, i.e. Allopathic and Ayurvedic treatment system. Over 60 countries have identified medical tourism as a national industry and some of the most popular among them are Greece, South Africa, Jordan, India, Malaysia, Philippines and Singapore. India is one of the most lucrative and leading destination for medical tourism because of its international quality of medical care at the lowest rates in comparison with other countries. India is an attractive medical tourism destination with specialized team of doctors and superlative treatments along with world-class exotic tourist attraction comparable to other countries in the world. The most popular treatments sought in India by medical tourists are alternative medicine, bone-marrow transplant, cardiac bypass, eye surgery, hip replacement, heart surgery, cosmetic surgery, dental care and other areas of advanced medicine. The cost of surgery can be one-tenth of what it is in the United States or Western Europe and sometimes even less. Our country is well known for the traditional systems of medicine, and for providing Ayurvedic treatments such as Ayurvedic oil massage therapy, herbal therapy, aroma therapy, spa and hydro therapy etc. that attracts large number of medical tourists. Besides these, Language is a major comfort factor that invites many foreign tourists to visit India for medical and health tourism. India has a large populace of good English speaking doctors, medical staff and guides. This makes it easier for foreigners to connect well with Indian doctors. Even with the global economic downturn, medical tourism in India has emerged as the fastest growing segment of tourism industry.

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Medical tourism providers or facilitators should have good knowledge of the topography of various places and hospitals offering medical tourism, so that they can give proper guidance to the foreign tourists and patients from abroad in choosing the best hospital. They should be aware of even minute particulars of health care and travel industry, laws and regulations governing medical tourism industries, Visa and other related requirements. They must possess excellent communication, organization and leadership skills and must have the ability to handle people, develop an understanding of the quality issues and general customer services. They must have up to date knowledge of pricing, content/treatments, hospital ratings, accreditation information plus latest updates on local and destination country's political/ visa restrictions policies and procedures.

Below are seven key findings from the interviews and literature review. A core set of soft skill competencies for entry-level employees in customer service positions include: customer service; communication; teamwork and interpersonal skills; organizational and planning skills; critical thinking and problem solving; creativity; culture sensitization; presentation and professionalism; work ethics (integrity and reliability); self-assessment; and ability to receive constructive feedback. Although definitions of entry-level positions and employee profiles differ widely across the service sector, a common denominator is widespread concern over the lack of soft skills, especially customer service, communication, teamwork and work ethics of new hires. Corporate training offerings are focused on technical skills and training manager level staff, although the service sector, particularly retail and hospitality companies, have begun to address the soft skills gap among entry-level employees to align them with company-wide values and norms, improve overall customer service and business performance and increase retention, especially in emerging economies. Companies generally partner with corporate training vendors to create and deliver training, and a large array of B2Bsolutions exist for career-employees. Select companies develop and deliver the training themselves. Yet, civil society has a critical role to play in reaching young, low-skilled entry-level employees in developing countries where the soft skills gap most needs to be addressed to empower youth and support a profitable business environment. The share of technology-based training is growing; and long-term cost efficient solutions such as e-learning, social media and m Learning are increasingly integrated into blended learning solutions that enable reach and support face-toface training in customer service skills. There is space for a civil society/private sector partnership and resulting initiative to develop an e-learning soft skills training for young entry-level employees as this segment has not yet been the core focus of soft skills training. More research needs to be done to test blended learning soft skills training initiatives to determine the business case for investing in them. Do they, for example, cut recruiting costs, reduce turnover, lead to higher retention rates and upward mobility, and increase worker productivity enough to make it a solid business investment for companies?

E-learning for Soft Skills TrainingChallenges and Opportunities According to industry experts and current literature on the topic, e-learning has considerable advantages for companies seeking to train, expand, and retain their workforce. The primary advantages include Creating cost-efficiencies. E-learning tools decrease the costs associated with purely trainer-led approaches by allowing multiple employees to reuse the same content, thus decreasing material reproduction costs Maximizing content use. Participants can reuse and review e-learning content as often as they wish making for a better and more intense learning experience. Meeting tech-savvy Gen-Y and Millennial expectations. E-learning enhances the technology and fastpaced environment young professionals experience personally and expect professionally. Harmonizing training principles and outcomes across a company. E-learning allows harmonization of training processes by disseminating the same content across training entities and within a company so that there is less variation in expected training outcomes than with decentralized training responsibilities. Providing flexible training opportunities. When integrated into daily work practice, e-learning provides on-the-spot or just-in-time learning opportunities which improve job performance and create new value. 90

 Increasing organizational flexibility. E-learning can either be self-paced or live, thus avoiding disruptions in the work place and giving learners opportunities to review the material at any time. The following three recommendations are presented as strategies for addressing current market gaps and improving soft skills training for entry-level employees in the service sector. 1. Develop an e-enabled product targeting a specific audience With the bulk of current soft skills research focusing on the skills needed by tertiary graduates, and industry-led training programs aimed largely at managerial and technical skills development, there is a pressing need for soft skills training for low-skilled job-seekers who are secondary school completers or dropouts, vocational training, or college graduates from two-year degree programs. Such a product could reach a broad global audience that may include low-skilled or inexperienced youth in the US, potential Gen-Y tech-savvy hires in OECD or emerging countries, and first-time, young employees in developing counties. The preferred product model to achieve this is a blended learning product with e-learning and/or m Learning modules teaching crossindustry core soft skills that are supported by webinars for on-the-go and just-in-time learning, face-to-face meetings and embedded workplace practice, and ideally supported by coaching/mentoring for advice, advancement, motivation, and retention. The preferred product would also allow for cost effective adaptation to make it relevant for a diverse group of young people, with differing levels of education and soft skills.

2.Make soft skills training comprehensive and discreet for young, entry-level employees across the service sector. New employees, above all the ones in high customer-contact positions, should be given the opportunity to systematically benefit from a specific and industry-relevant soft skills training that includes transferrable soft skills, such as customer service, communication, and teamwork skills. Given the short and long term benefits of improved customer service due to soft skills training, an overall training plan should give employees the opportunity to access e-learning or m Learning tools during work hours. Tracking when employees login, access data, and complete modules online would allow L&D departments or supervisors to control the overall activity. Face-to-face instruction that gives employees a chance to practice these skills with guidance and feedback provided from a senior employee would support skills acquisition. The soft skills training should be provided pre-hire by a qualified organization or at the time or post-hire immediately following an initial probationary/trial period by the employer. In all cases, the training must be clearly differentiated from any new-entry orientation or compliance training. 3. Establish a public-private partnership to combine and leverage expertise and experience. A joint effort between service sector companies and civil society organizations, such as IYF, that has a solid understanding of youth and industry needs and a robust life skills program, would leverage the experience of working with young people in local markets to provide soft skills training courses that meet the needs of this dual audience. Partners could collectively assess how relevant the blended learning model is for diverse groups of young people and how much adaptation is necessary to ensure positive outcomes. Finally, the partnership could work together to make the business case for soft skills training through a ROI analysis that looks at recruitment costs, turnover, productivity, and advancement.

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EMPLOYABILITY SKILLS FRAMEWORK Employability Skills definition: Skills required not only to gain employment but also to progress within an enterprise so as to achieve ones potential and contribute successfully to enterprise strategic directions. Employability Skills are sometimes referred to as generis skills or capabilities or key competencies. Personal attributes that contribute to overall employability: Commitment Honesty and integrity Enthusiasm Reliability Common sense Positive self esteem A sense of humour Loyalty Personal Presentation A balanced attitude to work and home life An ability to deal with pressure motivation Adaptability

Element (i.e. facets of the skill that employer identified as important noting that the mix and priority of these would vary from job to job) Listening and understanding Communication that Speaking clearly and directly contributes to Writing to the needs of the productive and audience harmonious Negotiating responsively relations across Reading independently employees Empathising and customers Speaking and writing in languages other than English Using numeracy Understanding the needs of internal and external customers Persuading effectively Establishing and using networks Being assertive Sharing information Working across different ages and Teamwork that irrespective of gender, race, religion contributes to or political persuasion productive Working as an individual and as a working member of a team relationships and Knowing how to define a role as outcomes part of the team Applying teamwork to a range of situations e.g. futures planning, crisis problem solving Identifying the strengths of the team members Coaching and mentoring skills including giving feedback Developing creative, innovative Problem solving that solutions contributes to Developing practical solutions productive Showing independence and outcomes initiative in identifying problems and solving them Solving problems in teams Applying a range of strategies to problem solving Using mathematics including budgeting and financial management to solve problems Applying problem solving strategies across a range of areas Testing assumptions taking the context of data and circumstances into account Resolving customer concerns in relation to complex projects issues Having a personal vision and goals Self Evaluating and monitoring own management that performance contributes to Having knowledge and confidence employee in own ideas and visions satisfaction and Articulating own ideas and visions growth Taking responsibility Skill

Skill

Element (i.e. facets of the skill that employer identified as important noting that the mix and priority of these would vary from job to job) Managing time and prioritiessetting time lines, coordinating tasks for self and with others Being resourceful Taking initiative and making decisions Adapting resource allocations to cope with contingencies Establishing clear project goals and deliverables Allocating people and other resources to tasks Planning the use of resources including time management Participates in continuous improvement and planning processes Developing a vision and a proactive plan to accompany it Predictingweighing up risk, evaluate alternatives and apply evaluation criteria Collecting, analysing and organising information Understanding basic business systems and their relationships Having a range of basic IT skills Applying IT as a management tool Using IT to organise data Being willing to learn new IT skills Having the OHS knowledge to apply technology Having the physical capacity to apply technology e.g. manual dexterity

Planning and organising that contributes to long and short term strategic planning

Technology that contributes to effective execution of tasks

Managing own learning Life-long Contributing to the learning community at the workplace learning that Using a range of mediums to learnmentoring, peer support contributes to and networking, IT, courses ongoing Applying learning to technical issues (e.g. learning about improvement products) and people issues (e.g. interpersonal and cultural and expansion aspects of work) in Having enthusiasm for ongoing learning employee and Being willing to learn in any settingon and off the job company Being open to new ideas and techniques operations and Being prepared to invest time and effort in learning new skills outcomes Acknowledging the need to learn in order to accommodate change

Initiative and enterprise that contribute to innovative outcomes

Adapting to new situations Developing a strategic, creative, long term vision Being creative Identifying opportunities not obvious to others Translating ideas into action Generating a range of options Initiating innovative solutions

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Although the soft skills of cultural appropriateness and language access have, up to now, been largely ignored in favor of a focus upon marketing medical and technical know-how and lower cost, they impact every facet of both financial success and customer satisfaction in medical tourism. Without them, marketing attempts will fall flat and may even steer prospective clients away from entire countries as well as individual medical facilities. Unless these facilities can promise and deliver appropriate care that meets the cultural needs, values and expectations in a language that is understood, medical tourists will not feel satisfied with care and will not recommend these facilities to friends, family and their local physicians. Cultural and linguistic competency may be soft skills, but they are necessary elements to growth of patient base, reputation and your bottom line. The culture of these potential clients will determine what types of services and benefits they expect and value most. The language, or actual words and phrases used to describe these benefits and services, will determine whether or not that particular location or facility will attract clients and encourage them to consider care at that site. Correct use of the primary languages of the targeted audiences is essential, as well. Sloppy grammar or use of unidiomatic phrases results in negative, rather than positive advertising! It tells perspective patients and medical partners that the care provided is also sloppy and uncaring; that the organization does not pay attention to detail, and that patient/ physician communication will be far from adequate at that facility. Organizations seeking patients from abroad can only expect to attract rather than discourage prospective patients and, thus, get the best bang for their marketing budget by making sure their web sites -- and all other marketing materials -- appeal specifically to the culturally determined values and measures of quality of that targeted audience, and are written by a trained native speaker of the language of the targeted patient population! Cultural and Linguistic Competence = Greater Patient Satisfaction, Fewer Medical Errors, More Return Patients & Patient Referrals It is important to recognize that, although a bilingual staff is the best way to assure patient/caregiver communication, it is not enough for organizations to allow staff to self-evaluate their fluency in another language. Knowledge and the ability to accommodate the patients cultural needs and expe ctations regarding both medical care and auxiliary services are also important factors in patient satisfaction and gaining referrals directly from former patients or from their local physicians. Even cultural factors, such as the appropriate form of address, knowledge and considerations of religious beliefs, taboos and dietary customs and restrictions, have a tremendous impact on patient satisfaction. It is important, for example, to know that prior to first obtaining permission, staff must not cut a Sikhs hair or remove the bracelets that may be attached to his wrist. Or, in which cultures it is necessary for a female physician to attend to a female patient, or even when the patients religion forbids the eating of certain foods. Make sure the patient is comfortable being in a foreign country and with the customs and languages that they do not know.

Have someone ready to greet them in their language. Make sure forms and medical information including follow-up and billing is provided in their native language. Try to insure that both the physicians and nurses who attend to them can communicate effectively in their language or through a professionally trained medical interpreter. Train physicians and nurses how to use interpreters effectively. Train both medical and non-medical staff in the cultural and religious beliefs and taboos that may affect satisfaction and compliance with care. Train both medical and non-medical staff in the language skills required to communicate with that population group. 94

Even if your country doesnt have malpractice laws, avoid risks of medical error through miscommunication. Hire professionally trained medical interpreters or contract with an outside face-to-face, phone or video interpreting service. Effective communication skills are essential to succeeding in any field but none more so than medical tourism. Research shows that failing to return telephone calls is one of the major complaints among consumers of international health travel services. Excellent telephone etiquette can ensure that clients calling from countries around the world will be treated courteously and respectfully the same way you enjoy being treated. Developed based on cross-cultural international best business practices, Telephone Skills for the Medical Tourism Professional prepares you to make a positive impression the first time, every time you interact with clients on the telephone. What better way to demonstrate your commitment to delivering excellent customer service? Eight areas of expertise: 1.Answering and responding to calls 2.Enhancing your voice quality 3.Improving listening skills 4.Asking the right questions to get the right answers 5.Managing calls 6.Returning calls properly and promptly 7.Using voice mail professionally 8.Delivering excellent customer service via telephone

Over the last decade, increasing numbers of hospitals around the world have begun to focus on medical tourism and providing customized services to international patients. The globalization of healthcare has led to a growing need for qualified and experienced professionals with international patient management skills. Certified International Patient SpecialistTM (CIPS) is a certification of expertise in the International Patient Services field, provided by the Medical Tourism Association.
The Certification for International Patient Specialist TM was created for: Healthcare professionals seeking the practical training and knowledge to effectively manage the international patient care process. These include: International department staff Hospital/Clinic administrators Doctors Marketing personnel Nurses Medical tourism facilitators Tourism operators Hotel staff Anyone about to enter the medical tourism/international patient field (These last 4 bullets need to be removed)

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Benefits of Becoming a Certified International Patient Specialist TM : Demonstrates to patients, employers and peers that you practice high international patient management standards That you possess the training and knowledge to successfully manage an international patient services program Sets yourself apart from the competition and shows colleagues your specialized expertise and commitment to the industry Shows that you are up to date with current practices in the international patient services industry through continuing education Opportunities for job promotion and career enhancement

Individuals who complete the Certified International Patient Specialist's TM Process will have a comprehensive understanding of: International patient expectations How to develop an International Patient focused Service Package The Lead/patient management process The International Service Staff and IT requirements for seamless patient management Procedure package pricing and bundling Risk management protocols (pre-screening patients, complication insurance, waivers, disclaimers) Key elements of an Aftercare program and Continuum of Care Strategy How to leverage customer word of mouth advertising

Benefits for Hospitals/Clinics: By requiring or recommending certification for your staff, you are ensuring that the most updated industry policies and current best practices are implemented at your hospital or clinic. Certified staff can help your organization maintain a competitive edge by increasing patient satisfaction scores. The MTA awards CIPSTM certification to International Patient Professionals who: Pass a comprehensive exam Meet professional experience requirements Meet educational requirements Maintain their international patient credentials through continuing education courses required in order to maintain CIPSTM certification

Certification Requirements: Attend certification training session, complete written exam, and possess moderate to advanced language skills in target market's language.

References Tr_0607_consumerinsights_Q0206.pdf Medical Travel Quality MTQUA.pdf Softskills_competencies_Report_IYF.pdf.pdf www.gmu.ac.ae/online-programs/medical-tourism-mediator www.medicaltourisminindia.org/ http://www.medicaltourismassociation.com/en/certified-international-patient-specialist.html www.medicaltourismmag.com Issue 28

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CHAPTER-9 FUTURE TRENDS IN MEDICAL TOURISM INDUSTRY

The history of travel for medical purposes is inseparable from that of the history of medicine itself, with evidence showing that for thousands of years man has been prepared to journey far from home to avail himself of treatment. Some early examples would be those of ancient civilizations discovering healing springs far from their city walls, which they would travel to in order to seek relief from their maladies. Throughout the ages and across the globe, medical tourism can be chronicled as different epochs that portray how the phenomenon has progressed over time. The market: The global economic downturn and medical tourism Forecasts for the global economy are not encouraging, recession in Europe, anaemic growth in the US and slow growth in the emerging market economies is anticipated for 2012. If we want that the medical tourism sector should grow, one must keep a watch on fundamental trends that affect businesses and markets in a recession. In the mature, developed economies (e.g. USA, Europe) continued unemployment and pressure on disposable income will influence demand in 2012. Consumers will minimize or reduce spending on healthcare where they can. This does not mean that hard pressed consumers will be flocking abroad for their operations to save money. Many will delay treatment, or in the case of optional surgery such as cosmetic surgery, they may not be able to afford it at all. Domestic prices for surgery will be driven down as hospitals apply marginal costing and prices to fill empty beds. In areas of treatment, where the need for treatment is income-inelastic, demand for medical tourism services will remain strong. Patients will continue to dig deep for services such as infertility treatment, stem cell treatment, and for surgery which is essential, life-saving or life changing. In emerging markets (such as Russia, China), the growth in incomes (and freedom to spend) is outstripping the development of domestic healthcare services and this may drive demand for medical tourism and present new opportunities.

The big question of present market?? Whether corporate or insurer paid medical travel will get off the ground in 2012? Will employers and insurers see medical travel as a realistic and credible option to reduce healthcare costs? Will their client and subscriber base actually buy in to the medical travel option if it is offered to them? As we look into the year 2013, medical tourism industry trends and expectations closely mimic trends expected in the hospitality industry. While cautious optimism is felt by many, it should by no means be assumed for 2013 in this industry. With heightened competitive environment locally, regionally and globally, medical tourism companies need to focus on emerging markets and create a differentiator as well as customer experience to increase revenue, client base, and branding in the wake of such trends. Due to the continued uncertainties of global economies, it is natural to expect heightened competition between medical tourism providers, because they are all seeking to either maintain or increase their client base as well as to get new clients. Technology leads the way in offering consumers the best that medical providers have to offer.

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Key issues the medical tourism industry faces in 2013

Increased Competition

Lack of Product Differentiators

Increased Competition A major trend for 2013 is in the increased competition, both globally as well as regionally and locally. Established medical providers must prepare to face a massive increase in competition. More medical providers are promoting medical tourism and the governments are involved too, with more healthcare regulations worldwide. Due to limited barriers when entering the medical tourism industry, providers will flock in this already competitive field. The multi-channel promotional environment, used by all involved in the industry to promote their products and services, is expected to further influence this fierce competition. Considering the growing competitive environment, medical providers need to stay on the top of their game when it comes to branding, marketing, and services. Increasing domestic and global presence today relies heavily on the virtual environment. Social media and visibility, accessibility, and not the least important - reputation are key. Availability of online information for consumers to do their research and understand their choices is important when selecting the provider. With increased transparency of available information online, the competition will be heighted in 2013 and beyond. Lack of Product Differentiators The large numbers of medical providers in the medical tourism industry makes it increasingly difficult to establish a clear product differentiator. Each and every medical provider is competing on cost, quality, and location attractiveness. In 2013 medical providers will invest more in an attempt to stand-out with their products and services. A blurring product differentiation and increased price pressure may result in declining revenue and lower profits. Growth in Emerging Markets Although the demand of medical tourism services in established markets appears to remain unchanged, it is precisely this demand that will have an impact with government regulations. Governments are attempting to curtail the money spent on people traveling abroad for medical care. Similarly, increasing numbers of local medical providers will develop products and services that can compete economically with medical tourism organizations. 98

This would require medical tourism providers to seek new opportunities in emerging markets. This will in turn, favor medical travel for citizens due to the ever-changing healthcare system. Cosmetic surgery is expected to be the biggest growth area over the next five years Dental treatment (43%), cancer treatment (43%) and infertility treatment (40%) are also expected to experience significant growth.

Trends in Medical Tourism

1. Getting Ahead in Today's Tough Economics Medical tourism providers must take a step back and thoroughly examine their medical practices, processes, systems, and services in order to compete in the industry. Heavy emphasis should be placed on: branding consumer experience creating sustainable infrastructure cost effective operations transparent and reliable information management. Branding and Recognition Branding and recognition will be essential for success in 2013. Clear brand messages and differentiator will be the key in attracting mainstream consumers in the medical tourism industry. In a highly competitive industry, the consumer will seek a well-established brand to reduce the risk and gain confidence on healthcare outcomes. Getting ahead in the medical tourism industry today relies heavily on reputation and loyalty. Consumer Experience The medical tourist will seek opinion from peers to understand and focus on their experience and will buy products and services that embrace and create superior consumer experience to build customer loyalty. Consumer experience will be the key differentiator in 2013 for medical providers and how they present this experience to the general public as an educational tool. Sustainable Infrastructure Medical tourism companies will gain a competitive advantage in 2013 by establishing and focusing on creating a sustainable infrastructure that includes the integration of people, process and systems. By leveraging cost-effective measures and optimization of the end-to-end processes, they will address the complexities of medical tourism business and offer a business advantage. Integrating technology could further enhance the overall business performance. A medical provider with a solid infrastructure that offers transparency, information, research, and a database of accumulated knowledge regarding doctors, surgeons, healthcare facilities, treatments, surgeries and procedures is essential for success. Information is power and consumers today want to be informed. They go through a large amount of information on the Internet before approaching, let alone making decisions, regarding medical travel. 2. The patient (and customer) service must come first In the Treatment Abroad Medical Tourism Survey 2011 (awaiting publication), 85% of medical tourists were satisfied with their experience of going to another country for treatment. BUT...15% were dissatisfied. The standard of care, the quality of treatment, the level of customer service and patient communication all come under fire from patients who have participated in the research. According to Rudy Rupak at Planet Hospital, his business success is based on disciple marketing former patients are what drive clients to us. Within the industry as a whole, the message that excellent customer service and outstanding treatment quality brings more customers is yet to be widely adopted. The sector continues to be plagued by the bad news medical tourism stories that appear in the press and media. I 99

see little change in 2012. Its going to be a very long haul for the industry to establish credibility and trust within the media and ultimately broaden its potential customer base. 3. The patients voice will get stronger As patients evolve into healthcare consumers, they are considering the purchase of healthcare in much the same way that they consider the purchase of any consumer good or service. And medical tourists are no different. They take a holiday and they write a review of the hotel or destination on Trip Advisor. They opt for surgery in another country, and they want to tell people what it was like...by word of mouth and increasingly online. In 2012, there will be more healthcare providers who see the benefit of encouraging patients to rate and review their services. They want the patients voice to be heard. They want to hear what went right AND what went wrong. Comparisons of healthcare quality are difficult on a national basis, and virtually impossible for a patient to make on an international basis. And this will not change next year or in the next decade. The patients voice is probably the best comparator that people currently have in choosing healthcare providers. It just needs the providers to buy into the concept. 4. Market concentration Fewer players because as the recession bites the weak will either go to the wall or will withdraw from the sector. We may finally see the appearance of some bigger players in what is a highly fragmented market in terms of providers and facilitators. If medical tourism is big business, there should be facilitators out there handling several hundred patients every month. Greater focus because successful medical tourism is about delivering services to niche market segments that has specific needs and requirements. And one of the biggest shortcomings in medical tourism marketing is lack of understanding of customer needs and failure to deliver to these needs Top destinations The U.S., Thailand and Singapore were ranked as the leading destinations in terms of quality and range of services provided to international patients. India, Thailand and the U.S. were named the most popular destinations in terms of patient numbers. In five years time, India, Thailand and Turkey will draw the highest number o f medical travelers, followed by the U.S., Germany and Singapore, respondents said. The U.K., U.S. and Russia were named as the leading source countries for international patients. 5.Joined up healthcare Criticism of medical tourism is often targeted at the lack of joined up healthcare. There are very few operators offering a truly coordinated approach to surgery and treatment abroad. Ask the average facilitator to define the clinical/care pathway for their patients and you will probably be met with a blank stare. If such pathways do exist, then they may be in place within the destination hospital, but the pathway starts on admission to the hospital and stops on discharge. The industry still hasnt overcome the problem of how to handle pre-admission and post-operative care at a distance. From the patients perspective, they are on their own when they return home. When complications or problems arise, many providers will make the standard fly back and well fix it offer, but this is probably the last thing that the patient wants to consider. 6. Growing Eastern System of Medicine: Ayurveda, Naturopathy, Yoga and Meditation The medical tourism industry has shifted its strength from surgical and non-surgical health care procedures towards eastern system of medicine like Ayurveda, Homeopathy, Naturopathy, Yoga and Meditation. These alternative systems of medicine lead to perfect physical and mental health. Tourists are made to feel relax and refresh along with the cure of diseases that attract them most towards such systems. These alternative traditional treatments are expanding aggressively in Malaysia, Thailand and India.

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These methods are safe and nontoxic than conventional therapies and cost is relatively lesser than surgical treatments. Rejuvenation and relaxation therapies are offered by the Asian countries at their world class spas. India is providing cosmetic makeovers through Ayurveda. Kerala (an Indian state) is concentrating on Ayurvedic way of treatments for the visitors and tourists and has gained the title of 'City of Ayurvada'. Thailand has set up spas and massages centre in hotels and near airports. The countries are putting up efforts to set up quality services near tourist destinations like coastal areas to offer tourist escape with healthcare pampering in one package. 7. Cosmetic Surgery: A Growing Medical Tourism Business Cosmetic surgery can remove deformities and enhance a person's appearance. An increasing number of people from both developed and developing countries prefer to go overseas for cosmetic surgery because of cost benefits. This has given strong impetus to the medical tourism industries of those countries, which are equipped with state-of-the-art cosmetic surgery infrastructure and attractive tourist destinations. These countries provide a combination of surgical expertise along with cutting edge plastic surgery procedures, treatments and therapies.

Analyzing the cosmetic industry at the country level, we have found that developing countries like India and Taiwan have performed well. Besides, the government support is essential for the development of cosmetic industry. They are combining the cosmetic treatments with medical tourism to attract patients with advanced infrastructure and low cost. Besides, other Asian countries like Thailand, Malaysia and Singapore have become the favorite destinations for the Breast surgery, Buttock lift, Face lift, Hair replacement, Laser skin resurfacing and Reshaping of the nose. India is preferred for liposuction cosmetic surgery. Argentina, Mexico and Costa Rica popularity as destination for cosmetic surgery is rising. They offer facilities with the world class hospitals and clinics.

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Medical Tourism Past, Present & Future Trends

4200BC
As early as 4200 BC, health recuperation included baths in the gushing thermal springs and fountains housed in lofty, grandlose temples The sumerians werethe first to host these temples of yore.

2000BC
Around 2000BC, people used bronze utensilsto drink from mineral rich thermal springs for the water health giving properties. These springs constituted as the preferred treatment destination.

1500BC
Ancient healthcare progresses in 1500 BC, when the Greeks foundation stone of the Asclepia Temple in the honour of the Godof medicine. Travellers came froms miles seeking recovery for therir illnesses.

14th-15th Centuries
the term solute per aqua"spa" was coined for the iron rich hot spring that were located the the town of Waters(ville d'eau)in france . the sap attracted the rich and famous from around the world.

12TH-13TH Centuries
Japan's hot mineral springs, widely known as Onsen catpured the attraction of warriors because of their culture properties. Egyptian hospitasls also received tourist attention.

300BC
The Greek civilistion showed growth n medical services. A small province in the Saronic Gulf. Epidemiology housed centers providing abdundant services including temples,gynasiums, steamb aths, culture farms, baths etc.

18th -19th Centuries

Over disorder,gout and bronchitis were major ailments. became the earliest form of hospital and provided welcome relief, with many traveling to them for cure.

20th Century
Cuba gained popularity for optical surgery, central America for dental procedure, Thailand for Plastic Surgery. Several other countries developed health care services that included spiritual healing and alternative medicines.

21st Century
With Technology no longer a constraint, remarkable advancements in specialised medical science sowed the seeds of intense competition to capture international paitents. This gave the rises of modern medical tourism.

Global Healthcare
Not only patients , but the services of doctorsand hospitals, as well as complimentary medicines, healthcareexperti se and knowledge wiill cross border to infuse true globalisation of healthcare.

Near Future
Medical Tourism is expected to make significant advances with intra country and intra-regional health related travel activities. International travel will be seloceted for significant saving, high quality of care and as a destination of choice.

Current Industry
More tha 50 countries now participate in medical tourism with developing countries grom Asia, Latin America, Middke East and Africa capturing the major segment. The competition is based on cost, quality, care and tourism activities.

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