Lancet: Medical tourism booms in India, but at what cost?

Medical tourism booms in India, but at what cost?

Priya Shetty

As India tries to position itself as a major player in global health care, how will its courtship of rich foreign patients affect the care of India's own people? Priya Shetty reports from Mumbai.
In a plush suburb of Mumbai in India, a doorman guards the entrance of a gleaming building. Inside, past the marble floors, chandeliers, beauty salon, and fine-dining restaurant, is an elevator that takes the elite up to their suites. Mumbai has its share of five-star hotels, but this is not one of them. It is the Kokilaben Dhirubhai Ambani Hospital, one of the latest additions to India's increasing number of private hospitals. These shiny symbols of the country's burgeoning economy have been attracting increasing numbers of medical tourists—patients from other countries who come to India for treatment that ranges from cataract corrections to cardiac surgery.

The medical tourism industry is growing fast, especially in emerging markets like India. The Confederation of Indian Industry predicts that India will see revenues of US$2 billion from medical tourism by 2012. Captivated by this economic potential, the Indian Government is actively courting international patients. Yet despite the industry's predicted growth of 30% in India, the country has not produced any national medical guidelines on this issue.
For doctors and ethicists, the lack of regulation is ringing alarm bells. For one thing, duty of care and accountability are particularly murky issues in cross-border health care. Additionally, Indian doctors are concerned about the knock-on effects of medical tourism on the local health-care system.

Many private hospitals in India are now seeking accreditation by the Joint Commission International (JCI), which has become a crucial stamp of approval for hospitals in developing countries seeking medical tourists. The number of JCI-accredited foreign medical sites worldwide tripled from 76 in 2005 to more than 220 in 2008.
The reasons why patients are willing to travel long distances for surgery tend to vary by region. In the USA, for example, a lack of health insurance can make treatment unaffordable (table). In the UK, patients get frustrated with long National Health Service waiting lists and the high cost of private care. Patients from the Middle East and Africa are drawn to India because the technology or medical expertise is lacking in their own countries.

The Indian Government, eager to expand its economy, has begun to aggressively court foreign patients through tourism campaigns that sell a unique mix of cutting-edge technology with ancient medical traditions in the form of ayurveda and yoga. The government has also created a special medical visa that lasts up to 1 year to make it easier for patients to enter the country. The result of this government cooperation has been an extraordinary expansion of corporate-owned hospitals across the country. Kokilaben is only 18-months old, but other private chains such as the Fortis Hospitals group, known for specialties such as cardiology, have been around for several years. Fortis Chief Executive Officer Vishal Bali says that the chain of 48 hospitals across India was built in less than a decade.

Although the American Medical Association, for example, issued guidelines on medical tourism in 2008, India has so far chosen to leave it to private institutes such as Fortis to make their own rules. This June, researchers concerned about the ethics of such self-regulation met at a conference on medical tourism held by Simon Fraser University (SFU) in Vancouver, Canada.
Valorie Crooks, who studies health services research at SFU organised the conference with Jeremy Snyder, a health ethicist at the university. Crooks says that medical liability is a serious concern. “In societies that are litigious in nature, such as the US, there is a concern that physicians will not want to provide follow-up care for patients treated abroad in case complications arise”, said Crooks. “There are no formal legal frameworks to protect international patients seeking medical care abroad”, agrees Indrajit Hazarika, who researches health-system strengthening at the Indian Institute of Public Health, Delhi. “In the event that some medical malpractice error does occur, it is very unlikely that the patient will receive any financial recourse in the foreign country”, he adds.

Suresh Rao, a paediatric cardiologist at Kokilaben hospital, estimates that about 15% of his patients come from abroad. Rao admits that the contract that patients sign with the hospital does not oblige him to provide aftercare. “If there is some issue, they will have to get seen by their home physicians”, he told The Lancet. Nevertheless, he says that he and other doctors at the hospital keep in touch with patients via email or phone because they view good follow-up as their moral responsibility. Vishal Bali says that doctors at Fortis also work hard to maintain links with patients after treatment, and the hospital chain has even subsidised the air fare for patients who have needed to return for follow-up treatment. “We don't at any point in time want to give an indication to our international patients that after the procedure we are not interested in their care.”

So far, there have been no major reports of such hospitals, in India at least, abandoning follow-up care. The competitive market-driven nature of the industry acts as an incentive for hospitals to ensure that patients are happy with their aftercare—hospital administrators say that many people use word-of-mouth recommendations. Bali says that Fortis safeguards both itself and patients by avoiding travel or tourism companies that do not have medical advisers. “All our health-care facilitators must understand the seriousness of medicine.”
In some ways, health insurance companies offer patients protection by vetting hospitals first. Mihir Bapat, a spine surgeon at Kokilaben, says that his international patients' insurance companies are “particularly careful in sanctioning treatment. They ask a lot of questions”.
However, Vivek Jawali, chief cardiothoracic surgeon at Fortis Hospitals, says that although Indian hospitals are behaving responsibly for now, “national guidance will come; it must”. Bapat is also strongly in favour of better national guidance. “Medical tourism is active but there are no laws per se as to how an institution manages it”. The guidance is crucial, he says, because in interactions with international patients “there can be language barriers, sociocultural barriers, and you need to understand those barriers to treat these patients.”

But ethicists are not just concerned about international patients. Increasingly, Indian doctors are worried about how gearing the health care system towards rich foreign patients will affect the care of India's millions of impoverished people. George Thomas, chief orthopaedic surgeon at St Isabel's Hospital in Chennai, India, and editor of the Indian Journal of Medical Ethics, spoke at the SFU conference in Vancouver. Thomas told The Lancet that hospitals designed to attract medical tourists have been built “by lobbying the government for cheap land to build the hospital, cheap loans to finance expenditure, and tax breaks. In a country, where the poorest are taxed on every item they buy, the concessions handed out to the rich are simply obscene.” Not only that, many hospitals are ignoring the responsibilities that such concessions come with, says Sunita Reddy, at the centre for social medicine and community health in Jawaharlal Nehru University in Delhi, who has co-authored a review of the effect of medical tourism on local health care.

A 2005 report by the Indian Government's public accounts committee investigated whether private hospitals in Delhi had kept their promise of providing some free health care in return for being sold land at hugely subsidised rates. Subsidised hospitals were asked to provide free care for 25% of inpatients and 40% of outpatients, explains Reddy. But the report concluded that most institutions had not offered this care. “The policy could have provided life-saving opportunities to some of those who are afflicted with complicated and deadly diseases but [who cannot afford] costly medical treatment”, says the report. “What started with a grand idea of benefiting the poor turned out to be a hunting ground for the rich in the garb of public charitable institutions.”

These criticisms are particularly important since India is trying to position itself as a key player in global health care. Crooks notes that “these countries are buying into the WHO's focus on renewing the commitments to primary health care made at Alma Ata, but instead we see these public dollars being shifted into private health care and the benefits for the public are really unclear.” Private hospitals are defensive about these criticisms. Bali says, for instance, that international patients tend to use high-end hospital suites “that would only be used by 15—20% of the Indian population anyway”. An average 10-min outpatient consultation in a private hospital in India costs between Rs500 and Rs1000. For many Indians, this would be half or more of their monthly salary. But Bali says that poorer sections of the population can still access care through government insurance policies.

Although claims that hospitals are reneging on promises to provide free care do seem to have some evidence behind them, researchers say the lack of data for the ethical fallout of medical tourism is a serious issue. “Countries that see medical tourism as a solution to development of their health-care centres should be cautious”, says Snyder, “because there are a lot of anecdotal stories about how medical tourism can harm health inequity, but without better data it's hard to make the argument that that's always the case or even often the case”.
Hazarika believes that there are genuine ethical concerns, but agrees with Snyder that “almost all the published reports on this issue are based on speculations and assumptions”. As well as better ethical guidelines, it is clear that India also needs government support to document the effects of medical tourism.

Outside Kokilaben's gleaming airconditioned walls, meanwhile, the chaotic reality of India, and the gap between rich and poor, has never been more evident. A sleek black car delivering a patient to the hospital speeds through a monsoon-flooded road, splashing a rag-clad beggar in the process. Used to the inequity of life in his country, he simply shakes himself off, shrugs, and moves to a drier spot.