Study on in Three Metropolitan Cities: , and CESS MONOGRAPH 42

Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai

K.S. Babu Ipsita Mohanty P. Usha

CENTRE FOR ECONOMIC AND SOCIAL STUDIES Begumpet, Hyderabad-500016 September, 2016 CENTRE FOR ECONOMIC AND SOCIAL STUDIES MONOGRAPH SERIES

Number - 42 September, 2016 ISBN 978-81-931589-5-1

Series Editor : M. Gopinath Reddy

© 2016, Copyright Reserved Centre for Economic and Social Studies Hyderabad Note: The views expressed in this document are solely those of the individual author(s).

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Published by : Centre for Economic and Social Studies Begumpet, Hyderabad-500 016 Ph : 040-23402789, 23416780, Fax : 040-23406808 Email : [email protected], www.cess.ac.in

Printed by : Vidya Graphics 1-8-724/33, Padma Colony, Nallakunta, Hyderabad - 44 Foreword The Centre for Economic and Social Studies (CESS) was established in 1980 to undertake research in the field of economic and social development in . The Centre recognizes that a comprehensive study of economic and social development issues requires an interdisciplinary approach and tries to involve researchers from various disciplines. The centre's focus has been on policy relevant research through empirical investigation with sound methodology. CESS has made important contributions to social science research in several areas; viz., economic growth and equity, agriculture and livestock development, food security, poverty measurement, evaluation of poverty reduction programmes, environment, natural resource management, district planning, resettlement and rehabilitation, state finances, education, health and demography. It is important to recognize the need to reorient the priorities of research taking into account the contemporary and emerging problems. Social science research needs to respond to the challenges posed by the shifts in the development paradigms like economic reforms and globalization as well as emerging issues such as optimal use of environmental and natural resources, role of new technology and inclusive growth. Dissemination of research findings to fellow researchers and policy thinkers is an important dimension of policy relevant research which directly or indirectly contributes to policy formulation and evaluation. CESS has published several books, journal articles, working papers and monographs over the years. The monographs are basically research studies and project reports done at the centre. They provide an opportunity for CESS faculty, visiting scholars and students to disseminate their research findings in an elaborate form. As part of Research Monograph Series, my colleagues have undertaken a study on Medical Tourism in the three metropolitan cities of India. The present Monograph titled "Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai" was based on field study in three cities. Medical tourism is an emerging concept to describe the rapidly-growing practice of traveling across international borders to obtain healthcare. India has become a preferred health destination for those who are living abroad as also those foreigners who are looking for a speedy and inexpensive treatment. One of the factors that the patients consider while looking for medical care outside of their country is the accreditation of hospitals. All the hospitals visited for the study were having national accreditation (NABH, NABL) and also few having international accreditation (JCI). The study looked into background characteristics of the foreign tourists seeking medical care, reasons for coming to India for treatment and source of information of foreign tourists to choose India for treatment, details of their medical and travel expenses, their perception about the quality of care, availability of translators, availability of care takers and ethical issues involved in Medical Tourism. The three metropolitan cities were selected because of the large number of foreign patients coming to the cities for treatment. The three cities are well connected to various global destinations. The hospitals here are well equipped with modern amenities and medical professionals CESS Monograph - 42 iv who are highly qualified. The major findings of the study reveal that medical tourism is on the increase in all the three cities. Medical tourists of all age groups and from different countries are coming to the three cities for treatment. Hyderabad had a high percentage of patients coming from Africa followed by Middle East countries while Chennai and Mumbai had patients mostly from Middle East countries. The medical tourists come for various health problems ranging from more serious problems such as cardiac problem and cancer and also more simple problems as master health check up. Medical Tourism combines medical treatment with tourism. However, for many of the patients in the study, travelling was not an important aspect during their stay in India. Though many of the international patients did not face any problems in getting visa, almost all the patients were of the opinion that getting visa to India was a lengthy process and could be frustrating for patients, particularly those with serious health problems. It is necessary for the government to look into this matter and ensure speedy visa clearance and immigration by developing simplified systems of issuing medical visas. Visa can also be extended depending on the condition of the patients. The study shows that English speaking capabilities of nurses and paramedical staff in the hospitals is poor. Interpreters are required who assist foreign patients in their communication with doctors and healthcare attendants. Though almost all the hospitals visited had interpreters for the patients but there were only few interpreters in each hospital, sometimes only one, who were not always available. The satisfaction level of international patients with the quality of care and relationship with doctors and staff of the hospital is an important parameter that influences the success of Medical Tourism. Almost all the international patients coming to the three cities for treatment were satisfied by their overall experience in the hospitals. The future of medical Tourism in the three cities seems promising. With the availability of world class facilities in private hospitals that are continuously upgraded and internationally recognized and highly qualified medical professionals and skilled health staff, India has great potential to attract more and more international patients for medical treatment. However, if India has to become a world player in medical tourism industry, public and private health sectors and voluntary organizations should create a congenial atmosphere for the growth of medical tourism. I hope the recommendations from the study will be useful to the policy makers, health professionals and academicians.

S. Galab Director, CESS Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai v

CONTENTS Page No.

Foreword iii List of Maps and Figures ix List of Tables xi Acknowlegments xvii Executive summary xix 1: Introduction 1 1.1 Tourism 1 1.2 Medical Tourism 4 1.2.1 History of Medical Tourism 5 1.2.2 Contemporary Medical Tourism 5 1.2.3 Countries Promoting Medical Tourism 6 1.2.3a Source Countries of Medical Tourists 7 1.2.3b Medical procedures 7 1.2.4 Medical Travel Companies 9 1.2.5 Medical Tourism in 9 1.3 Medical Tourism in India 10 1.3.1 The Role of Private Sector in Promoting Medical Tourism in India 12 1.3.2 Government Initiatives to promote Medical Tourism in India 13 1.3.3a Contribution of Medical Tourism to Indian Economy 15 1.3.4 Constraints of Medical Tourism 15 1.4 Reasons for Medical Tourism 16 1.5 Medical and Travel Expenses of Tourists 17 1.5.1 Cost Comparison 17 1.5.2 Medical Tourism Insurance 18 1.6 Quality of Health Care 19 1.6.1 Quality and Safety Concern 19 1.6.2 Qualification of Medical Staff 20 1.6.3 Accreditation of Hospitals 20 1.7 Ethical Issues 21 1.8 Need of the Study 24 1.9 Objectives of the Study 24 2: Methodology 25 2.1 Location of Study Area 25 a) Hyderabad 27 b) Chennai 28 c) Mumbai 29 2.2 Data Collection 30 CESS Monograph - 42 vi

2.3 Questionnaires for Primary Data Collection 31 2.3.1 Foreign Patient Questionnaire 32 2.3.2 Hospital Questionnaire 33 2.3.3 Observation Tool 33 2.4 Pilot Study 34 2.5 Limitations 34 3: Medical Tourism in Hyderabad 37 3.1 Introduction 37 3.1.1 A Demographic Profile of 38 3.1.2 Tourism in Andhra Pradesh 38 3.1.3 Health Care in Andhra Pradesh 38 3.2 Hyderabad 40 3.2.1 Demographic Profile of Hyderabad 40 3.2.2 Tourism in Hyderabad 41 3.2.3 Health Care in Hyderabad 43 3.2.4 Medical Tourism in Hyderabad 44 3.2.5 Accreditation of Hospitals 44 3.3 Hospitals Visited for the Study 46 3.4 Study of International Patients 54 3.4.1 Background Characteristics of International Patients 54 3.4.2 Background Characteristics of Family Members of International Patients 60 3.4.3 Reasons for Coming to India 68 3.4.4 Visa 73 3.4.5 Medical and Travel Expenses 76 3.4.5a Insurance 77 3.4.5b Expenditure 78 3.4.5c Tourism 80 3.4.6 Availability of Translators/Interpreters 81 3.4.7 Quality of Care 83 3.5 Ethical Issues 95 3.6 Summary 96 4: Medical Tourism in Chennai 99 4.1 Introduction 99 4.1.1 A Demographic Profile of 100 4.1.2 Tourism in Tamil Nadu 100 4.1.3 Health Care in Tamil Nadu 101 4.2 Chennai 102 4.2.1 A Demographic Profile of Chennai 102 4.2.2 Tourism in Chennai 103 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai vii

4.2.3 Healthcare in Chennai 104 4.2.4 Medical Tourism in Chennai 104 4.2.5 Accreditation of Hospitals 105 4.3 Hospitals Visited for the Study 106 4.4 Study of International Patients 110 4.4.1 Background Characteristics of International Patients 110 4.4.2 Background Characteristics of Family Members of International Patients 114 4.4.3 Reasons for coming to India 119 4.4.4 Visa 123 4.4.5 Medical and Travel Expenses 125 4.4.5a Insurance 125 4.4.5b Expenditure 127 4.4.5c Tourism 128 4.4.6 Availability of Translators/interpreters 130 4.4.7 Quality of Care 131 4.5 Ethical Issues 140 4.6 Summary 143 5: Medical Tourism in Mumbai 145 5.1 Introduction 145 5.1.1 A Demographic Profile of Maharashtra 146 5.1.2 Tourism in Maharashtra 146 5.1.3 Health Care in Maharashtra 147 5.2 Mumbai 148 5.2.1 A Demographic Profile of Mumbai 148 5.2.2 Tourism in Mumbai 149 5.2.3 Health care in Mumbai 150 5.2.4 Medical Tourism in Mumbai 151 5.2.4a Future Prospects for Medical Tourism in Mumbai 151 5.2.5 Accreditation of Hospitals 152 5.3 Hospitals Visited for the Study 154 5.4 Study of International Patients 162 5.4.1 Background Characteristic of International Patients 162 5.4.2 Background Characteristics of Family Members of International Patients 166 5.4.3 Reasons for Coming to India 171 5.4.4 Visa 176 5.4.5 Medical and Travel Expenses 177 5.4.5a Insurance 177 5.4.5b Expenditure 179 5.4.5c Tourism 180 CESS Monograph - 42 viii

5.4.6 Availability of Translators/Interpreters 182 5.4.7 Quality of Care 183 5.5 Ethical Issues 193 5.6 Summary 195 6: Comparison of findings across the cities of Hyderabad, Chennai and Mumbai 198 6.1 Background Characteristics of International patients in the three cities 199 6.2 Countries of International Patients 200 6.3 Health Problems of International Patients 202 6.4 Reasons for coming to India 203 6.5 Visa 205 6.6 Insurance 207 6.7 Expenditure 208 6.8 Tourism 209 6.9 Availability of Translators/Interpreters 209 6.10 Quality of care 210 6.11 Hygiene and Cleanliness of the Hospital 212 6.12 Accommodation of the Attendants 213 6.13 Quality of Food 213 6.14 Whether they will come in future for any Treatment 214 6.15 Would they suggest others about the Hospital and Country? 214 6.16 Suggestions 215 References 219 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai ix

List of List of Maps

Map Map Particulars Page No. No. 2.1 Location of study area 26 2.2 Andhra Pradesh 27 2.3 Tamil Nadu 28 2.4 Maharashtra 29 3.1 Andhra Pradesh Map 37 3.2 Hyderabad 40 4.1 Tamil Nadu 99 4.2 Chennai 102 5.1 Maharashtra State in India 145 5.2 Mumbai in Maharashtra 148 List of Figures

Fig Figure Particulars Page No. No. 1.1 Foreign Tourists Arrivals in India, 2010-2014 2 1.2 Foreign Exchange Earnings (FEE), 2010-2014 3 1.3 FTAs in India for Medical Treatment, 2010-2012 11 3.1 Foreign Tourists Arrival in Andhra Pradesh, 2010-2013 39 3.2 Foreign Tourist Arrival in Hyderabad, 2010-2013 42 3.3 Foreign Tourist Arrivals in Andhra Pradesh from 2010 to 2013 42 3.4 Foreign Tourist Arrivals in India from 2010 to 2013 42 4.1 Foreign Tourist Arrivals in Tamil Nadu, 2010-2013 101 4.2 Foreign Tourists Arrival in Chennai, 2011-2012 103 5.1 Foreign Tourists Arrival in Maharashtra, July 2009-March 2014 147 5.2 Foreign Tourist Arrival in Mumbai, July 2009- March 2014 150 6.1 Gender of the International Patients 200 6.2 Education Wise Distribution of International Patients 201 6.3 Country Wise Distribution of International Patients 202 6.4 Health Problem of International Patients 203 CESS Monograph - 42 x

6.5 Reasons for coming to India 204 6.6 Whether faced difficulties, while applying for Visa 206 6.7 Difficulties faced while applying for Visa 206 6.8 International patients with Insurance Coverage 207 6.9 Expenditure incurred on Treatment and Stay 208 6.10 International patients interested in Tourism as well 209 6.11 Availability of Interpreters 210 6.12 Suggestion to others about the Hospital 215 List of Tables

Table Tables Particulars Page No. No. 1.1 Foreign Tourists Arrivals (FTAs), 2010-2014 2 1.2 Foreign Exchange Earnings, 2010--2014 3 1.3 Foreign Tourists in India for Medical Treatment 10 1.4 Cost Comparisons (US$) 18 2.1 Details of Sample in Three Cities 26 2.2 Selection and Sample 30 2.3 Details of the sampled hospitals. 31 3.1 Demographic Profile of Andhra Pradesh 38 3.2 Foreign Tourist Arrivals in Andhra Pradesh from 2010 to 2013 38 3.3: A Demographic Profile of Hyderabad as per 2011 Census 41 3.4: Foreign Tourist Arrivals in Hyderabad from 2010 to 2013 41 3.5 Healthcare Facilities (Public and Private) in Hyderabad as of 2010-2011 43 3.6 Lists of Hospitals in Hyderabad 47 3.7 Hospitals Visited for the Study 48 3.8 Gender Distributions of International Patients 55 3.9 Distribution of International Patients by Age Group 56 3.10 Distributions of International Patients by Marital Status 57 3.11 Education-Wise Distribution of International Patients 58 3.12 Occupation-Wise Distribution of International Patients 59 3.13 Age Wise Distribution of Family Members 60 3.14 Distribution of Family Members by Marital Status 61 3.15 Education-wise Distribution of Family Members 61 3.16 Occupation-Wise Distribution of Family Members 62 3.17 Country-Wise Distribution of International Patients 63 3.18 Health Problems of International Patients 65 3.19 Reason for Choosing India for Treatment 69 3.20 Who Suggested About Place and Hospital 70 3.21 Medium of Contact with the Hospital 71 3.22: Facilities that Attracted the International Patients to This Hospital 72 CESS Monograph - 42 xii

3.23 Difficulties Faced in Their Country 73 3.24 Any Difficulties faced, While Applying for Visa 74 3.25 Whether the Staff at the Indian Embassy Friendly and Helpful 75 3.26 Distribution of Patients by Type of Visa 75 3.27 How Many Days did You Get the Visa for 76 3.28 Do They Have Health Insurance 77 3.29 Would They Have Been Able to Come to India without Health Insurance 78 3.30 Did Health Insurance Give them Any Additional Incentive to Come to India 78 3.31 Cost of Treatment and Stay 79 3.32 Cost of Entire Trip to India 79 3.33 Planning to do Any Tourism While being in India 80 3.34 If yes, Places you would Like to Visit 81 3.35 Problems with Language 82 3.36 Whether the Hospital Provides Interpreters for those with Language Problem 82 3.37 Problems, if any, during Admission at the Hospital 83 3.38 Whether the Staff was Courteous, Polite, Friendly and Helpful 83 3.39 Procedures Suggested by the Doctors 84 3.40 Stages of Treatment 85 3.41 Whether Satisfied With The surgical Procedure 86 3.42 Whether Satisfied With the Doctor 86 3.43 Whether Satisfied With the Care Takers of the Hospital 87 3.44 Whether Hospital Providing as Prescribed by Doctors 87 3.45 If not, where are they Available 88 3.46 Whether Information Regarding Recovery Given to Family by Doctor/Nurse 88 3.47 Whether the Nurse/Doctor Explained the Purpose of to be Taken at Home 89 3.48 Whether Satisfied With the Hygiene and Cleanliness at the Hospital 89 3.49 Whether Hospital Provided Accommodation for Attendant/s 90 3.50 Quality of Food served at the Hospital 91 3.51 Whether Patients had Received any Prior Information about their Discharge 91 3.52 Whether the Doctor had Prescribed Any Medicine Post their Treatment 92 3.53 Availability of medicine in their Country for those Medicine had been prescribed 92 3.54 Whether the Alternate of the Medicine Prescribed Available in Your Country 93 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai xiii

3.55 Will You Come Here For Follow up Treatment? 93 3.56 Would You Come Here in Future if You Need Any Treatment 94 3.57 Would You Like to Suggest to Others this Hospital in Your Country 94 4.1 A Demographic Profile of Tamil Nadu as per 2011 Census 100 4.2 Foreign Tourist Arrivals in Tamil Nadu, 2010-2013 100 4.3 A Demographic Profile of Chennai as per 2011 Census 102 4.4 Foreign Tourists Arrival in Chennai from 2010 to 2013 102 4.5 Lists of Hospitals in Chennai 106 4.6 Hospitals visited for the Study 107 4.7 Gender Distributions of International Patients 110 4.8 Distribution of International Patients by Age Group 111 4.9 Distributions of International Patients by Marital Status 112 4.10 Education-Wise Distribution of International Patient 112 4.11 Occupation-Wise Distribution of International Patients 113 4.12 Age-wise Distribution of Family Members 114 4.13 Distribution of Family Members by Marital Status 114 4.14 Education-Wise Distribution of Family Members 115 4.15 Occupation-wise Distribution of Family Members 116 4.16 Country-wise Distribution of International Patients 117 4.17 Health Problems of International Patients 118 4.18 Reason for Choosing India for Treatment 119 4.19 Who Suggested this Place and Hospital 120 4.20 Medium of Contact with the Hospital 121 4.21 Facilities that Attracted the International Patient to this Hospital 122 4.22 Difficulties Faced in Their Country 122 4.23 Any Difficulty faced while Applying for Visa 123 4.24 Whether the Staff at the Indian Embassy Friendly and Helpful 124 4.25 Distribution of Patients by Type of Visa 124 4.26 How Many Days did you Get the Visa For 125 4.27 Do They Have Health Insurance 126 4.28 Would they have been able to come to India without Health Insurance 126 4.29 Did Health Insurance Give any Additional Incentive to Come to India 127 4.30 Cost of Treatment and Stay 127 CESS Monograph - 42 xiv

4.31 Cost of Entire Trip to India 128 4.32 Planning to do Any Tourism While being in India 129 4.33 If yes, which Place you would like to Visit 129 4.34 Problem with Language 130 4.35 Whether the Hospital Provides Interpreters for those with language problem 130 4.36 Problems, if any, during Admission at the Hospital 131 4.37 Whether the Staff was Courteous, Polite, Friendly and Helpful 131 4.38 Procedures Suggested by the Doctor/s 132 4.39 Stages of Treatment 132 4.40 Whether Satisfied with the Surgical Procedure 133 4.41 Whether Satisfied with the Doctor/s 133 4.42 Whether Satisfied with the Care Takers of the Hospital 133 4.43 Whether Hospital Providing Medicines Prescribed by Doctor/s 134 4.44 Whether Information Regarding Recovery given to Family by Doctor/Nurse 134 4.45 Whether the Nurse/Doctor Explained the Purpose of Medicine to be Taken at Home 135 4.46 Whether Satisfied with the Hygiene and Cleanliness of the Hospital 135 4.47 Whether Hospital Provided Accommodation for Attendant/s 135 4.48 If no, How did They Arrange Accommodation for Attendant 136 4.49 Quality of Food served at the Hospital 136 4.50 Whether Patients had Received any Prior Information about their Discharge 137 4.51 Whether the Doctor had Prescribed Any Medicine Post their Treatment 137 4.52 Availability of medicine in their Country for those medicines had been prescribed 138 4.53 Whether the Alternate of the Medicine Prescribed Available in Your Country 138 4.54 Will You Come Here for Follow up Treatment 139 4.55 Would You Come here in Future if, You Need any Treatment 139 4.56 Would You Like to Suggest to Others this Hospital in Your Country 140 5.1 A Demographic Profile of Maharashtra 146 5.2 Foreign Tourists Arrival in Maharashtra, July 2009-March 2014 146 5.3 A Demographic Profile of Mumbai 149 5.4 Foreign Tourist Arrivals in Mumbai from July 2009 to March 2014 149 5.5 Healthcare in Mumbai as of 2010-2011 150 5.6 Lists of Hospitals in Mumbai 152 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai xv

5.7 Hospitals Visited for the Study 153 5.8 Gender Distributions of International Patients 162 5.9 Distribution of International Patients by Age Group 163 5.10 Distribution of International Patients by Marital Status 164 5.11 Education-wise Distribution of International Patients 164 5.12 Occupation-wise Distribution of International Patients 165 5.13 Age-wise Distribution of Family Members 166 5.14 Distribution of Family Members by Marital Status 167 5.15 Education-wise Distribution of Family Members 167 5.16 Occupation-Wise Distribution of Family Members 168 5.17 Country -Wise Distribution of International Patients 169 5.18 Health Problems of International Patient 171 5.19 Reason for Choosing India for Treatment 172 5.20 Who Suggested this Place and Hospital 173 5.21 Medium of Contact with the Hospital 174 5.22 Facilities that Attracted the International Patient to This Hospital 174 5.23 Difficulties faced by patients in their Country 175 5.24 Any Difficulties faced, While applying for Visa 176 5.25 Whether the Staff at the Indian Embassy Friendly and Helpful 176 5.26 Distribution of Patients by Type of Visa 176 5.27 How Many Days Did You Get the Visa For 177 5.28 Did they have Health Insurance 178 5.29 Would They Have Been Able to Come to India without Health Insurance 178 5.30 Did the Health Insurance Give Any Additional Incentive to Come to India 178 5.31 Cost of Treatment and Stay 179 5.32 Cost of Entire Trip to India 180 5.33 Planning to do any Tourism While being in India 181 5.34 If yes, Places You Would Like To Visit 182 5.35 Problems with Language 182 5.36 Whether the Hospital Provides Interpreter/s for those with language problem 183 5.37 Problems during Admission at the Hospital 183 5.38 Whether the Staff was Courteous, Polite, Friendly and Helpful 184 5.39 Procedures that the Doctors Suggested 184 CESS Monograph - 42 xvi

5.40 Stages of Treatment 185 5.41 Whether Satisfied with the Surgical Procedure 185 5.42 Whether Satisfied with the Doctor/s 186 5.43 Whether Satisfied With the Care Takers of the Hospital 186 5.44 Whether Hospital Providing Medicines Prescribed by Doctor/s 186 5.45 Whether Information Regarding Recovery Given to Family by Doctor/Nurse 187 5.46 Whether the Nurse/Doctor Explained the Purpose of medicine to be taken at Home 187 5.47 Whether Satisfied With the Hygiene and Cleanliness at the Hospital 187 5.48 Whether Hospital Provided Accommodation for Attendant/s 188 5.49 If no, how Did They Arrange Accommodation for Attendant/s ? 188 5.50 Quality of Food Provided in the Hospital 189 5.51 Whether Received Any Information about Your Discharge 189 5.52 Whether the Doctor Prescribed any Medicine after their Treatment Was Over 190 5.53 Availability of medicine in their Country for those Medicine had been prescribed 190 5.54 Whether the Alternate of the Medicine prescribed available in Your Country 191 5.55 Will you come here For Follow up Treatment? 191 5.56 Would You Come Here in Future, if You Need Any Treatment 192 5.57 Would You Like to Suggest to Others this Hospital in Your Country 192 Acknowledgements Many professionals have helped us in the completion of the project entitled, "Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai". This report would not have been possible without their support and guidance. First and foremost, we are grateful to our Director, Prof S. Galab for his encouragement and guidance at various stages of the study. The team extends special thanks to the Project sponsor, Indian Council of Social Science Research (ICSSR), Government of India, for entrusting the project to CESS. The team expresses its sincere gratitude to the hospital staff in Hyderabad, Chennai and Mumbai for their assistance during the field work. In Hyderabad, the team is grateful to Mr. Goparaju Sreenivas Rao, Senior Manager, International Business Development, Basavatarakam Indo American Cancer Hospital and Research Institute (also for allowing us to take photographs), Ms Manjula ES, Patient Care In-Charge, L.V. Prasad Eye Institute, Mrs. K. Shanti, Manager (PR), Krishna Institute of Medical Sciences, Dr. Gopikrishnan, Hospital Superintendant, Care Hospital, Mr. Sunil Rao, Assistant Manager, Patient Care, Asian Institute of Gastro-enterology, Dr Shyam Sundar, Hospital Superintendant, Continental Hospital and Dr. Birendra Kumar, Hospital Administrator, Kamineni hospital. The team offers it's thanks to Mr. Joshua T. I, Assistant Manager, International Business, Global Hospital and Health city, Ms Jetty Thampi, Incharge, International Patient Care and Services, Sri Ramachandra Medical Centre and Ms Sneha S., Deputy Manager, International Business, Fortis Malar Hospital in Chennai. In Mumbai, the team is thankful to Ms Victoria, Coordinator, International Patient Wing, Raheja Hospital, Dr. Wrinkle, Coordinator, International Patients Department, Asian Heart Institute, Mr. Vineet Naik, Coordinator, International Patient Wing, Hinduja Hospital, Dr Ansari, Head, International Patient Marketing, Jaslok Hospital, Dr Nazar Siddique, Head (HR), Global Hospital and Dr Miheed Dalal, In-Charge Clinical Administration, Kokilaben Dhirubhai Ambani Hospital. The team expresses sincere thanks to Dr. P. Prudhvikar Reddy for his help during the study. We would like to thank Prof. M. Gopinath Reddy for his suggestions on the draft report. The Authors wish to thank two referees of the report, Dr, P. Satya Sekhar, Professor of Health Management and Bio-Statistics, Indian Institute of Health and Family Welfare (IIHFW), Hyderabad, and Prof T.V.Sekher, Professor, Department of Population Policies and Programmes, International Institute for Population Sciences (IIPS), Mumbai for their detailed comments and helpful suggestions which has added quality to the report. We are thankful to Mr. R. H. Itagi for editing the manuscript. The team is thankful to Mr. B Sreedhar for his secretarial assistance. We would like to offer our thanks to Mr. S Joseph Nirmalraj for conducting the field work in Chennai. Our thanks are also to Dr. P. Ganesh, Mr. B. Narsaiah and Mr. B. Srinivas for actively participating in the field work in Mumbai. A special thanks to CESS supporting staff and library for their help during report writing. Last, but not the least, the team is thankful to all the respondents for their ungrudging help and cooperation without whom the study would not have been completed. Authors

Executive Summary The present study entitled, "Study on Medical Tourism in three Metropolitan cities - Hyderabad, Chennai and Mumbai" looks into the background characteristics of foreign tourists visiting India for treatment, their reasons to choose India for treatment and their perception regarding the quality of care provided by the hospitals. India has become a preferred health destination for those who are living abroad as also those foreigners who are looking for a speedy and inexpensive treatment. One of the important factors that the patients consider, while looking for medical care outside of their country is the accreditation of hospitals. Hospital accreditation ensures a high quality of treatment and care in the hospitals and raises the confidence level of the patients. Most of the hospitals visited in the three cities have been accredited. In Hyderabad, excepting Asian Institute of Gastroenterology, all the hospitals visited have been accredited by NABH. Basavatarakam Indo American Cancer Hospital and Research Institute, CARE Hospital, Krishna Institute of Medical Sciences and Kamineni Hospital also have NABL accreditation. Basavatarakam Indo American Cancer Hospital and Research Institute also has TUV (OHSAS) accreditation, while Krishna Institute of Medical Sciences has ISO accreditation. In Chennai, all the hospitals visited, excepting Billroth Hospital, have been accredited by NABH. Global hospital also has NABL and HALAL accreditations and Fortis Malar hospital has ISO accreditation. Similarly in Mumbai, all the hospitals, excepting Camballa hospital, have been accredited by NABH. Kokilaben hospital and Hinduja hospital also have CAP accreditation. Asian Heart Institute, Hinduja hospital and Nanavati hospital also have ISO accreditation. All the hospitals visited across the three cities also provide special services for international patients like electronic transfer of medical reports, special diet, accommodation for patients' companion/s, on-line counselling, etc. A few hospitals like Basavatarakam Indo Americal Cancer Hospital and Continental hospital in Hyderabad, Billroth, Sri Ramachandra Medical centre and Fortis malar hospital in Chennai and Sl Raheja and Kokilaben Ambani hospital in Mumbai have separate wings for international patients. The staffs of all the hospitals visited across the three cities have been specially trained in dealing with international patients. However, this study observes that most of the international patients come to these hospitals mainly because of the presence of specialized doctors rather than of any other factor. A summary of the findings emerging from the three cities of Hyderabad, Chennai and Mumbai is given below. CESS Monograph - 42 xx

The number of international patients we contacted was 54 in Hyderabad, 50 patients in Chennai and 50 in Mumbai. In Hyderabad, the international patients were from Africa, Middle East countries, South Asian countries, North America, Uzbekistan and China. However, more than half the patients (55.6%) were from Africa followed by Middle East countries (27.8%). Out of 30 patients from Africa, 12 (40%) were from (West Africa), 12(40%) from East Africa including Tanzania, , Somalia, Rwanda and Zambia, 5 from North Africa and 1 from Central Africa.In Chennai, the international patients were from Africa, Middle East and South Asian countries. Most of the patients were from Middle East (48%) countries followed by patients from Africa (46%). Out of the total patients from Middle East countries, 17 were from followed by 6 from . In Mumbai also, 50% of the patients were from Middle East countries. There were 26% from Africa, 10% from South Asia and Europe each and 4% from Australia. Thus, most of the patients were from Africa in Hyderabad, while in Chennai and Mumbai,most of the patients were from Middle East countries. In Hyderabad, more than half of the patients (59.3%) were males and 40.7% females. More number of patients were primary educated (25.9%) followed by graduates (24.1%). Out of the 50 international patients in Chennai, 68% were males and 32% females. Education-wise,most of the patients were graduates (38%), while 26% were secondary educated and 24% primary educated. And in Mumbai, the number of males was 66% and that of females 34%. More numbers of patients were married than unmarried across the three cities. In all the three cities, more number of patients were in the less than 50 years of age category. Looking at the occupational structure of the international patients, in Hyderabad,a little more than half of the patients were engaged in various kinds of occupation, while 30% were not working and 15% were children.In Chennai, most of the patients were into various kinds of occupation, while 28% were not working, and 6% were children and 8% were students. In Mumbai also, 18% were not working, 8% were students and a majority were into various kinds of jobs. The health procedures for which the international patients came to Hyderabad for treatment were varied and diverse. Out of the total patients, 13 (24.1%) came for cancer treatment, 22.2% for cardiac treatment, 11.1% patients for treatment of gastro intestinal problems and 9.2% each for treatment of neurological and ophthalmic problems. However, the presence of more number of patients with cancer and cardiac problems may be due to the fact that more patients were from two specialized hospitals of cancer and heart. The maximum number of international patients in Chennai had Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai xxi come for cardiac treatment (18%) and 16% of the patients for neurological problems. International patients had also come for other problems like liver, kidney, urological, gynaecological, orthopaedic, and cancer. There was 1 patient for plastic surgery. Patients had also come for simple procedures like physiotherapy and master checkup.In Mumbai also, more patients had cardiac problems. Out of the 50 patients, 12(24%) had cardiac problems, 9(18%) orthopedic problems, 7(14%) cancer and neurological problems each. An overwhelming number of patients (90.7%) gave specialization of the doctor/s as the reason for choosing Hyderabad for treatment, while low cost of treatment was the reason for 31.5% of the patients for choosing India. And in the case of 18.5%, treatment was not available in their country. Long waiting time in their country was the reason for choosing India in the case of only 5.6% of the patients. In Hyderabad, more than half of the patients had been told about the hospital and place by their friends and relatives (68.5%). A few had been suggested by the doctor/s at their place. An overwhelming number of patients (98%) chose Chennai because of the specialization of the doctor/s followed by 48% giving low cost of treatment as the reason for choosing Chennai, and 12% came to Chennai because treatment was not available in their country. About the hospital, 60% of the patients had been told by their friends and relatives and 46% by the doctors at their place. Almost the same number of patients had contacted hospital/ s over the phone and online. Similarly, in Mumbai also, doctors' specialization was the reason for 84% of the patients for choosing India for treatment. In the case of 40%, treatment was not available in their country, while low cost was the reason for 20% of the patients. Only 12% had come due to a long waiting time in their country. In Mumbai, a majority of the foreign patients had contacted the doctor and hospital over the phone and online and a few also through consultants or agents in their country. Thus, specializations of the doctor/s seems to be the main reason behind choosing India for treatment, followed by the low cost of treatment in India. In Hyderabad, a majority of the patients (75.9%) said they didn't face any difficulties while applying for visa. The patients felt that the staff at the embassy should be a little more compassionate with people seeking visa for treatment purpose. A few felt that it was very difficult to get medical visa.If the visa is urgent they charge double the money. A few of the patients, therefore, prefer tourist visa.A few had come with both medical visa and tourist visa for the attendant/s.In Chennai also, an overwhelming 94% of the patients didn't face any problem, while applying for visa. Among the patients, 80% had medical visa, 8% tourist visa and 10% both medical and tourist visas. In Mumbai also, 94% of the international patients didn't face any problem, while applying for visa and 96% had medical visa. CESS Monograph - 42 xxii

An overwhelming percentage (88.9%) of the patients in Hyderabad had come without insurance coverage and out of the remaining patients, who had come with insurance, would have come even without insurance. Most of the patients in Chennai also (92%), had come without insurance, while 6% had insurance. In Mumbai, however, more than half of the patients (58%) had come with insurance. Most of those who had come with insurance across the three cities would, anyway, have come to India even without insurance coverage. In Hyderabad the patients who gave information about their treatment cost, spent 5931.99 dollars, on an average, ranging from a minimum of 29.91 dollars to a maximum of 23000 dollars. In Chennai, the average amount of money spent by patientswas11418.14 dollars, ranging from a minimum of 242.55 dollars to a maximum of 64680.00.In Mumbai on an average, the patients spent 6754.48 dollars, ranging from a minimum of 392.75 dollars to a maximum of 37704 dollars. In Hyderabad, both the minimum and maximum amount spent was less as compared to Chennai and Mumbai. The expenditure depends on the type of health problems and duration of the stay in the hospital. Tourism was not a priority for patients who had come for treatment to these three cities. Only 38.9% of the patients in Hyderabad wanted to visit different places after their treatment was over. The rest were not interested in any kind of tourism. In Chennai also, only 24% of the patients wanted to visit a few nearby places. In Mumbai, 32% of the international patients wanted to visit places after their treatment was over. In Hyderabad, a majority (75.9%) of the patients did not have any problem with the language. Most of them who had some problem were provided with an interpreter, though some complained that the interpreter was not always available. In Chennai also, a majority (64%) did not have any problem with the language. And the rest 36% of the patients with some language problem were provided with interpreters by the hospital. In Mumbai, 74% of the respondents didn't have any problem with the language, while 13 patients did have some problem and they were provided with interpreters by the hospitals. The overall experience of the international patients in Hyderabad was satisfactory. An overwhelming number of the patients (94.4%) did not face any problem, while getting admitted. Most of the patients found the staff in the hospital friendly, courteous and helpful. The patients were advised to go through all the routine tests before any treatment was done even if they had undergone all the tests in their country. All the patients who had undergone surgery were satisfied with the surgical procedure. Almost all the patients Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai xxiii were satisfied with the doctor/s. However, three patients were of the opinion that the doctor/s had not come for post operative checkups. All the patients were satisfied with the caretakers of the hospital. In Chennai also, the patients were satisfied with their overall experience in the hospital. Only one patient had to wait for long before admission was done, while all the rest did not face any problem during admission. All the patients found the staff in the hospital helpful, courteous and friendly. All the patients who had undergone surgery were satisfied with the surgical procedure, while 40% of the patients were yet to be operated upon and in the case of 18%, no surgery was required. A majority of the patients (98%) were satisfied with the doctor/s and all were satisfied with the care takers at the hospital. In Mumbai, all the patients were satisfied with the overall experience in the hospital/s. The patients found the hospital care takers polite, courteous and helpful and they didn't face any problem during admission. The patients were advised to go through specific diagnostic techniques depending on the health problems. A majority of the patients (68%) were still continuing with the treatment and all of them were satisfied with their doctor/s. Most of the patients across the three cities were satisfied with hygiene and cleanliness at the hospital/s. In Hyderabad, 87% were satisfied with hygiene and cleanliness at the hospitals and according to a few there was room for improvement. In Chennai, 98% of the patients found the hospital/s clean and hygienic. In Mumbai as well, 98% were satisfied with hygiene and cleanliness at the hospital/s. Accommodation was provided to all the patients and one attendant by the hospitals. In the case of 94.4% patients in Hyderabad, accommodation was provided by the hospital/ s and the rest three patients did not have any accompanying attendants. In Chennai, in the case of 88% patients, the hospital/s had arranged for accommodation of the attendants and the rest 12% had to arrange accommodation on their own. Most of them arranged it in an A star hotel. In Mumbai, the hospital/s provided accommodation for 41(82%) patients, while 16% had arranged their own accommodation. Regarding the quality of food, in Hyderabad, most of the patients were not very satisfied with the food provided in the hospital/s. Only 16 out of 54 patients found the food decent, while for 3, it was excellent. However, in Chennai, most of the patients were satisfied with the food provided in the hospital/s. Out of the 50 patients, 50% found the food decent, while for 18%, it was excellent, and for 8%, it was good. In Mumbai, only 14% of the patients were dissatisfied with the food, whereas the rest were satisfied CESS Monograph - 42 xxiv with the food. This study thus shows a mixed response from the medical tourists across the three cities regarding the quality of food provided by the hospital/s. Almost all the patients (98.1%) in Hyderabad were sure that they would come to the same hospital, if required, for treatment in the future. An overwhelming number of the international patients (98.1%) expressed that they would suggest to others in their country about the hospital. In Chennai, 94% of the patients reported that they would come in the future to the same hospital, if required, for treatment and 96% said they would suggest to others in their country about the hospital/s and the country. In Mumbai, 52% said they would come to the same hospital, while the rest (24%) were not sure even though they were, overall, satisfied with the treatment at hospital/s. All the patients in Mumbai would suggest to others in their country about the hospital and the country. The complexity of international rules and norms influence the medical tourists' decision to travel to a particular country for treatment. It is required to set up a strong regulatory system so that, if anything goes wrong, it would be convenient for the medical tourists to approach local courts or medical boards. The existence of multiple ministries in the decision and policy making process aggravates the inefficiencies and makes the process of decision making tedious and lengthy. Empirical evidences regarding the health and safety risks related to medical tourism are limited. Knowledge about the risks faced by medical tourists mostly comes from news media reports. More research is required in this area in medical tourism. A further research can be done in areas such as legal safeguards, security etc. Moreover, the present study was limited to Hyderabad, Chennai and Mumbai only. In future a bigger sample size including other regions like , etc, which happen to be the medical tourism hubs, should be taken into consideration. 1. Introduction

Medical Tourism is the result of globalization and development in information technology. Increasing number of individuals are crossing their national borders in search of affordable and timely medical care. This could also be due to prolonged waiting hours and the non-availability of particular types of treatment in their countries. Patients opting for plastic surgery or gender change procedures may prefer going to another country with a view to safeguarding their privacy. Some of the countries where medical tourism is actively being promoted include Thailand, Malaysia, Singapore, India etc. In this context, many medical tourism companies are involved in organising cross-border health services. The quality of medical services and safety available in hospitals are important for promoting medical tourism. Many hospitals in India are accredited by accreditation bodies like Joint Commission International (JCI), National Accreditation Board for Hospitals and Healthcare Providers (NABH) etc., to ensure international medical standard services. Medical travel insurance is also included in the health plans of patients travelling abroad for treatment. The Introduction chapter looks into the following aspects: Section 1.1 deals with tourism in general; section 1.2 touches on medical tourism which includes the history of medical tourism, contemporary medical tourism, countries promoting medical tourism, source countries of medical travellers, medical procedures, medical travel companies and medical tourism in Asia; section 1.3 focuses on medical tourism in India including the private sector, government initiatives towards promoting medical tourism, contribution of medical tourism to the Indian economy, visa issues and challenges involved in medical tourism; section 1.4 looks into the reasons underlying medical tourism; section 1.5 outlines in detail the medical and travel expenses of medical tourists including cost comparison and medical tourism insurance; section 1.6 dwells on health care including quality and safety of medical travellers, qualification of medical staff and accreditation of hospitals; section 1.7 looks into the ethical issues related to medical tourism; section 1.8 explains the need for the study, followed by the objectives of the study in section 1.9. 1.1. Tourism Tourism is a global phenomenon including travel for recreation, leisure or business purposes. The World Tourism Organization defines tourism as "activities of people travelling to and staying in places outside their usual environment for not more than one consecutive year for leisure, business and other purposes". Tourism forms one of CESS Monograph - 42 2 the major components of the service sector of the Indian economy. It contributes around 6.11 percent of Gross Domestic Product (GDP) and Foreign Exchange Earnings (FEE) besides providing employment to millions. The new National Tourism Policy (Government of India, 2002), the Eleventh Five Year Plan (Planning Commission, 2008) and the Draft Approach to the 12th Five Year Plan (Planning Commission, 2011) reports highlight the importance of tourism sector in terms of its contribution to GDP and employment generation. It also proposed to focus on the creation of an adequate tourism infrastructure like modernization and expansion of airports, better hotel accommodation facilities, and improved road connectivity to tourist destinations. Estimates of Foreign Tourists Arrivals (FTAs) and Foreign Exchange Earnings (FEEs) are important indicators of tourism.

Table 1.1: Foreign Tourist Arrivals (FTAs), 2010-2014 Year FTAs (in millionRs.) Percentage change over the previous years 2010 5775692 11.8 2011 6309222 9.2 2012 6577745 4.3 2013 6967601 5.9 2014 7703386 10.6 Source:Ministry of Tourism, 2015

Figure 1.1: Foreign Tourist Arrivals in India, 2010-2014

Source: Ministry of Tourism, 2015 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 3

The FTAs in the Indian context have continued to grow from 57,75,692 in 2010 to 69,67,601 in 2013 to 77,03,386 in 2014. During 2012 India registered a positive growth of 4.3% over 2011. FTAs during the period January to December 2014 show an accelerated growth of 10.6% to 7.62 million as compared to FTAs of 6.97 million with a growth of 5.9% during January to December 2013 over the corresponding period of 2012. Tourism happens to be the most important sector in the country from the view point of Foreign Exchange Earnings (FEEs). As per the monthly estimates prepared by Ministry of Tourism, FEEs from tourism in India for 2012 amounted to Rs.94,487 crore as compared to Rs.77,591 crore for 2011 registering a growth of 21.8 % over 2011. FEEs again show an increase of 11.5% at Rs.1,20,083 crore for 2014, as compared to FEEs of Rs 1,07,671 crore with a growth of 14.0% during January to December 2013 (Ministry of Tourism, 2015).

Table 1.2: Foreign Exchange Earnings, 2010--2014 Year FEEs (Rs. Crore) Percentage Growth over the previous years 2010 64889 20.8 2011 77591 19.6 2012 94487 21.8 2013 107671 14.0 2014 120083 11.5 Source: Ministry of Tourism, 2015

Figure 1.2: Foreign Exchange Earnings (FEE), 2010-2014

Source: Ministry of Tourism, 2015 CESS Monograph - 42 4

According to the Ministry of Tourism, Foreign Tourist Arrivals (FTAs) to India were up 2.3% per cent at Rs.5.89 lakh in August 2015 as against Rs.5.76 lakh in August 2013. Between the period January and August 2015, FTAs stood at Rs. 50.68 lakh, a growth of 4.5 per cent against Rs. 48.51 lakh in January-August 2014. And Foreign Exchange Earnings (FEEs) from tourism were up 3 per cent at Rs. 82,225 crore in August 2015 as against Rs.79,803 crore in August 2014 (Tourism, 2015). The percentage of foreign tourists including Non-Resident Indians (NRIs) and Persons of Indian origin (PIOs) coming to India for medical and health purposes constitutes 4.8%, according to a study by National Council of Applied Economic Research (NCAER) and with the number of medical tourists to India increasing every year, medical tourism is increasing as well (NCAER, 2010). 1.2. Medical Tourism Tourism in the recent times is being combined with healthcare. Health and wellness covers a broad range of aspects, from healthy diets and healthy lifestyles to personal care and hygiene. There is also a significant increase in the demand for health care due to the demographics of different countries. The older population in relation to the total population is increasing which in turn puts pressure on the demand for health care. And it becomes difficult to deal with the increase in health care demand. These result in the deterioration of services and also a decrease in access to health care services. This may be due to long hours of waiting and high costs involved. And this leads patients to opt for healthcare in places out of their country either to save on money or to avoid long waiting hours for treatment (Sundar, 2012). Medical tourism is an emerging concept initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders for seeking health care. Governments all over the globe are highlighting it as 'International standard healthcare services at affordable prices.' It combines free time, leisure, fun relaxation, amusement and recreation together with wellness and healthcare packages (Ajmeri, 2012; Sundar, 2012). Views expressed by various researchers about Medical Tourism: ● Medical tourism can be defined as the provision of 'cost effective' personal health care/ private medical care in association with the tourism industry for patients needing surgical healthcare and other forms of specialized treatment (Ajmeri, 2012). ● A journey that patients take from one country to another country to get cost effective and efficient medical treatment, followed by a great vacation at some of the most beautiful locations is called medical tourism (Shanmugam, 2013). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 5

● Medical Tourism may be defined as the provision of cost-effective medical care with a due consideration to quality in collaboration with the tourism industry for foreign patients who need specialized treatment and surgery (Sharma, 2013). ● Medical tourism can be generally defined as a combination of cost control and tourism for clients (patients) requiring surgical and all other types of treatment (Mishra, 2014). 1.2.1. History of Medical Tourism Medical tourism has been there since earlier times. During the third millennium B.C., ancient Mesopotamians travelled to the temple of a healing God or Goddess at Tell Brak, Syria, in search of a cure for eye disorders. Greeks and Romans also travelled by foot or ship to spas and cult centers all around the Mediterranean. The Asclepia Temples, dedicated, in honor, to the Greek God of medicine, were some of the worlds' earliest 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 the prime destinations for the European upper classes looking to soothe their ills. From the 18th century onwards, wealthy Europeans travelled to Nile from Germany. In the 21st century, low cost travel has taken the industry beyond the healthy and desperate. South Africa specializes in medical safaris for those visiting the country for safari, with a stopover for some treatment. Indian system of medicine like and Unani system of medicine were very famous with peoples from different countries coming for their treatment and healings. In Roman Britain, patients took the waters at a shrine at Bath, a practice that continued for 2,000 years. At first, mere travelling was considered to be a good therapy for mental and physical wellbeing. Spa towns and sanitariums may be considered an early form of medical tourism. In the eighteenth century England, for example, patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis (Ajmeri, 2012; Rastogi and Bhardwaj, 2012; Uma, 2011). 1.2.2. Contemporary Medical Tourism Medical Tourism has been rapidly growing in the recent years with the worldwide medical tourism market growing at the rate of 15-25%, while at rates highest in North, Southeast and South Asia (Ajmeri, 2012). An individual looking for healthcare procedures outside of his/her own country because of high costs and long waiting periods can be termed as a medical tourist. He/she may combine his/her treatment with post operation vacation. The proportion of medical tourists has increased in the last four and five years. This CESS Monograph - 42 6 going out of one's own country may be due to various reasons. In countries like the USA, people who are without health insurance, may seek treatment in other countries where treatment is available cheap to avoid large out-of-pocket sums. In some countries, people may opt to go to other countries for treatment because they don't want to face lengthy waiting periods in their own countries. Thus, either because of low costs, shorter waiting periods or just to visit other countries, medical tourism is on the increase in recent times. According to an article in Forbes, as mentioned by Rutherford in his article, the medical tourism industry is showing a marked growth. An estimated 150,000 foreigners sought care in 2004 in India alone and this number is increasing at the rate of about 15% annually (Rutherford, 2009). 1.2.3. Countries Promoting Medical Tourism Medical tourism is growing and diversifying. The countries where medical tourism is being actively promoted include South Africa, Jordan, India, Philippines, Singapore, Malaysia, etc. In 2005, an estimated 500,000 Americans travelled abroad for seeking health care. A majority of them travelled to Mexico and Latin American countries and also to Singapore, India and Thailand. In The United States, in case of people with health insurance, third parties (insurers, employers, and government) pay for about 87% of the health care. So patients pay only 13% out of pocket for every dollar they spend on health care. A much higher percentage of out-of-pocket private health spending is observed in countries with growing entrepreneurial medical markets. For instance, patients pay 26% of health care spending out of pocket in Thailand, 51% in Mexico, and 78% in India. When patients contribute more of their own healthcare spending, providers are more likely to compete for patients based on price. Consequently, these countries have more competitive private health care markets (Sahu, 2008). Malaysia is one of the preferred medical tourism destinations for its modern private healthcare facilities and highly efficient medical professionals. Being a Muslim country, it attracts medical tourists from Middle East and North Africa nations. Currently the largest numbers of medical tourists are coming from Indonesia. Thailand continues to be the medical Tourism leader globally. Chantal and Siripen estimated that about 35% of the medical tourism is contributed by patients from South East Asian nations. Singapore's medical tourism strategies are built on its high quality medical care, trustworthy and internationally accredited hospitals (Mun, Peramarajan, and Nuraina, 2014;Herberholz1 and Siripen Supakankunti, 2014). Although medical technologies have been improving, the United States is still leading the world in certain medical areas. Due to the global recession in 2008, there has been Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 7 a decline in the inbound medical tourism to US. Domestic patients in the US tend to seek less expensive treatment in other countries. According to a study by Horowitz, 2007, US patients who have hip replacement surgery in India or Costa Rica save approximately 75% of the cost. In view of the low treatment costs, many Asian and Latin American countries have become of late preferred destinations for medical tourism (Giacalone, 2011). 1.2.3a. Source Countries of Medical Tourists One of the main reasons why medical tourists travel to different countries for treatment is that they can combine a high class medical treatment at relatively low costs with a relaxed vacation while recuperating. According to the research study report of Deloitte Development LLC (2008), an estimated 750,000 Americans travelled abroad for medical reasons. Going by an article in International Medical Travel Journal (2011), every year 5000 medical tourists from Oman travel mostly to India and United Kingdom for medical treatment. Nearly 8500 medical tourists from UAE go to different countries, particularly The United States, Germany, Thailand and Singapore. International patients who are wealthy people travelling to the United States in search of a high technology medical care come from Latin America, The Caribbean Islands, Europe and the Middle East. Singapore attracts patients from neighboring countries such as Indonesia, Malaysia, Indochina, South Asia with nearly half of the patients coming from Middle East. Patients coming to Thailand for medical needs travel from Japan, the US, South Asia, UK, Middle East and other ASEAN countries. However, Thailand has deliberately concentrated on the Japanese market since many doctors have been trained in Japan with nurses and other staff taught to speak Japanese (Ricafort Kristine Mae, 2011). Malaysia, as a Muslim country, attracts medical tourists from the Middle East, while currently attracting the highest number of patients from Indonesia. The Indian Ministry of Tourism reported that 171,021 foreign tourists had visited India for medical purpose in 2012, an increase of about23% corresponding to the previous year. Most of the medical tourists are from South Asia, Africa and Middle East (Mun et al, 2014). 1.2.3b. Medical procedures Health care procedures and treatments for which medical tourists travel to foreign countries may include cardiac surgery, joint resurfacing or replacement, ophthalmologic care, cosmetic dentistry and oral surgery, organ and stem cell transplantation, gender reassignment surgery, in-vitro fertilization and even executive health check-up. Thailand, as a medical tourism destination, is popular for organ replacement surgery, dental care, cosmetic surgery, cardiac surgery and orthopedic surgery. Malaysia also offers various popular advanced treatments for foreign patients which may include cardiac procedures, orthopedic, CESS Monograph - 42 8 cancer treatment, fertility treatment, cosmetic surgery and general health screening. Malaysia also offers traditional and complementary medicine as alternative medical treatments. Singapore is attracting patients at the high end of the market for advanced treatments like cardiovascular, neurological surgery and stem cell therapy. USA and European countries, especially UK and Germany, are able to attract foreign patients for high quality and specialized care. According to an article in Forbes (2008), the availability of advanced medical technology and sophisticated training of physicians is the driving force behind the growth of foreigners travelling to the United States seeking healthcare. In India, the most popular sought after treatments by the medical tourists are cardiac surgery, orthopedic, dental care, cosmetic surgeries, organ transplant and surrogacy (Mun et al, 2014; Ricafort Kristine Mae, 2011). India also offers a wide range of treatments from alternative Ayurvedic therapy to coronary bypass and cosmetic surgery. Ayurveda, an old system of medicine, developed in . It attracts patients from Middle East, Europe and other developing countries. Patients from neighboring countries also come due to cultural similarities because of which it is easy to adjust. According to a recent estimate, the market size of Ayurveda is about USD1.4 Billion, and this market is expected to grow at about 20% per year over the next five years. The major purpose for nearly 78.9% of Ayurvedic tourists is rejuvenation followed by curative purposes, while 89.5% of them like to revisit the Ayurvedic centers. The Department of Tourism, in partnership with Confederation of Indian Industries (CII), organizes shows and conferences on medical tourism which are attended by prominent medical tourism hospitals, medical insurance companies and travel operators (Joseph, 2012). India, along with Ayurveda, also has Sidha system of medicine, Unani system, and Yoga. The Sidha system of medicine depends on the clinical acumen of the physician after a proper observation of the patient, pulse and clinical history. The Unani System believes that our body is made up of four main elements like earth, air, water and fire which determine the temperature of the body. This system believes in the prevention of diseases and promotion of health. Naturopathy believes that one's unnatural habits with respect to living, thinking, working, sleeping, or relaxation and the environmental factors disturb the normal functioning of the body, thus causing diseases. Human body has inherent self-healing powers which happen by changing the unnatural habits. Yoga is also an age old Indian system found by sages and saints in India several thousand years ago. It is an instrument of self evolvement and enlightenment through physical and mental well-being (Dawn and Pal, 2011). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 9

1.2. 4. Medical Travel Companies The selling of health services mainly through advertisement across the global market is undertaken by medical care industries. They entertain clients from countries having medical procedures with very high costs, coordinate travel to less expensive health care facilities, and charge fees for organizing transportation, accommodation, and treatment. The internet, inexpensive telecommunications, and economy in air travel help them send patients to hospitals that offer low budget health care. Leading medical brokerages in the United States include Planet Hospital, Global Med Network, World Med Assist, Med Journeys, and Med Retreat. Individual hospitals or private hospital chains target price-conscious customers wanting procedures not covered under private health insurance or publicly funded health plans. Health care is packaged together with more commonplace tourist attractions. Marketing campaigns try to link health care to adventure, relaxation, and holiday fun (Turner, 2011). 1.2.5 Medical Tourism in Asia Medical Tourism is on the rise even as many countries around the world are developing it. Agencies are being set up to promote less expensive health care for potential foreign visitors mainly from the developed countries. Asia medical tourism market was expected to double by 2015 from its market in 2011. Mainly three countries- Thailand, India and Singapore were expected to control more than 80% of the market share by 2015. In addition, Philippines, South Korea, Malaysia and Taiwan are also catching up. Thailand is the leader in medical tourist arrivals with more than 40% share in Asia medical tourist arrivals in 2011. The study by Noree, Hanfield and Smith (2014) shows that 4000 medical tourists came from UK to Thailand for treatment accounting for 3.75% of the medical tourists. Among them 69% were males and 31% females with the largest group being between 45-54 years. Male members were older than females with almost 11% of the patients being above 65years. The average outpatient expenditure amounted to 467USD while that of inpatients to 13,955 USD per admission. The study also reveals that some medical tourists returned to Thailand for other types of treatment (Noree, Hanefeld, and Smith, 2014). Malaysia has seen an impressive growth in respect of medical tourism industry. Malaysia targets countries which have poor or inadequate medical facilities like Indonesia, Myanmar, Vietnam and Laos. The image of being a Muslim country helps Malaysia develop medical tourism in Muslim countries like , Brunei and Middle East countries. Countries with having high medical service costs and also long waiting periods are also targeted by Malaysia. According to the Association of Private Hospitals in Malaysia, nearly 375,000 foreign patients sought health services in 2008 (Anon, 2012). CESS Monograph - 42 10

Taiwan's medical tourism has become one of the biggest attractions for mid to high income Chinese tourists (Dey, 2013) even though it has entered the medical tourism industry only in the recent times. It has an advanced economy, a stable social and political climate and multiple tourism resources. Taiwan's excellent and cost effective medical care services along with a convenient transportation facility are drawing medical tourists from different countries. In 2008, approximately 5000 patients travelled to Taiwan for health checkups and cosmetic surgery and the number increased to 40,000 in 2009 (Liu, 2012). India, according to a Renub Research Report, happens to be one of the first countries to have recognized the potential of medical tourism. It was estimated that by the year 2015, India would receive nearly half a million medical tourists annually. Singapore medical facilities are considered to be the best in Asia, but its treatment costs are bit costlier as compared to its competitors. South Korea is a fast-growing medical tourism destination. It was forecast that by 2015, South Korea would attract more than 300 thousand medical tourists (Dey, 2013). Medical Tourism in India is discussed in detail in the next section. India, with its low cost advantage and the emergence of several private hospitals, represents one of the fastest growing markets. 1.3. Medical Tourism in India Medical tourism is a growing sector in India. India's rich history and culture as also various tourist spots like landscapes, forests, historical sites, rich culture and innumerable festivals have always attracted foreigners. It has a well-developed healthcare system throughout the country. Indian hospitals are well equipped with the latest technology and highly qualified and experienced staff that can provide timely and quality medical treatment to patients. Statistics suggest that the medical tourism industry in India is worth $333 million(Rs 1,450 Cr) (Babu and Swamy, 2007).Among the foreign tourists visiting India, a quarter visited for business and professional purposes, a little more than a quarter for leisure, holiday and recreation, a little less than a quarter for visiting friends and 20% for other purposes. Around 3% visited for medical treatment (Ministry of Tourism, 2012). Table 1.3: Foreign Tourists in India for Medical Treatment Year FTAs in India Share of Medical Tourists who visited India (In percent) 2010 5775692 2.7 2011 6309222 2.2 2012 6577745 2.6 Source: Ministry of Tourism, 2015 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 11

Figure 1.3: FTAs in India for Medical Treatment, 2010-2012

Source: Ministry of Tourism, 2015

India happens to be one of the first countries to have promoted medical tourism through extending special tax incentives to hospitals providing medical tourism. India's medical tourism sector was expected to experience an annual growth rate of 30%, thereby making it a Rs. 9,500-crore industry by 2015. India has a large number of medical professionals and scientists in the world due to its long history of medical education and high investments in medical research. Moreover, due to the large population of India, surgeons have more experience in some of the new medical techniques. There is a relatively less bureaucratic delay, when it comes to accepting new medical procedures also. The cost of coming to India for treatment is also relatively low because of the presence of a number of airways offering competitive airfares. Even tele-consultancy is available for expert opinions. An estimated number of 150,000 patients travel to India for accessing low-priced healthcare procedures every year. An increase in the number of medical tourists every year denotes that medical tourism in India is flourishing despite recession in the West (Reddy, 2013; Sharma, Anupama Sharma Anjana, 2012; Sharma, 2013; Sundar, 2012; Uma, 2011). India ranks second in the world in respect of medical tourism after Thailand. According to a study by Sharma, during 2012, India was the fifth most visited country for medical services. A large number of Americans come here for cardiac and orthopedic procedures. Because of the increasing number of medical tourists from America, Canada, and Europe, medical travel to India is growing by 30% a year (Sharma, 2013).Thus, medical tourism is showing an upward trend in India with its skilled medical manpower, high technology, CESS Monograph - 42 12 and quality service care. India can also boast of an English speaking staff, no undue waiting time for surgeries, and an affordable price compared to other countries (Godwin, 2004). According to a market research report "Booming Medical Tourism in India", medical tourism in India is the fastest growing industry despite the economic slowdown. A few big private healthcare providers such as Apollo, Fortis, Wockhardt and Max are engaged in creating their individual brand awareness in overseas markets through tie- ups with insurance companies and patient facilitation centers. However, if India were to become a world player in medical tourism industry, all the parts of state and central governments, private sector and voluntary organizations should work towards the growth of medical tourism (Joseph, 2013; Prakash, Tyagi, and Devrath, 2011; Shanmugam, 2013; Roy, 2008). 1.3.1. The Role of Private Sector in Promoting Medical Tourism in India The health sector in India has witnessed an enormous growth in the private and voluntary sector. The private sector (including corporate hospitals) has become a flourishing industry equipped with the most modern technologies. It is estimated that 75-80% of the healthcare services are provided by the private sector. Moreover, with one of the largest pharmaceutical industries in the world, India has its own drug production and also exports drugs to many countries. India's healthcare quality is on par with American standards with some Indian medical centers providing services that are uncommon elsewhere. In addition to the private sector, public sector hospitals like All India Institute of Medical Sciences (AIIMS) have been receiving patients from different countries mainly for complex surgical procedures. The Group is the largest healthcare group in India having 7000 beds across 38 hospitals. Apollo's business began to grow in the 1990s. Indian expatriates were the first patients returning home for treatment, leading, in turn, to major investments in this sector. After these patients from Europe, The Middle East and Canada started coming in for treatment, Apollo started providing facilities like local travel arrangements, accommodation for relatives, locker facilities, provision of cuisine options, provision of interpreters, arrangements with leading resort chains for post-operative recuperation, etc. Moreover, patients do get information about the hospitals and treatment from websites and advertisements in in-flight magazines. Amrita Enterprises Private Ltd and Intersight Holidays Private Ltd, in association with Kerala Tourism Development Council, Amrita Institute of Medical Sciences have developed a product called Kerala Health and Holiday card, which can be renewed like any other health insurance scheme and is valid for one year. The card provides health care services and holiday experiences through dedicated and reliable services. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 13

Global Health Tours, a UK based company established by UK medical professionals helps people with medical needs plan treatment abroad (Babu and Swamy, 2007). Medical tourism facilities help in developing the private health sector. Building more private hospitals to deliver medical tourism helps India's health care in many ways like providing additional beds for the poor, increasing non-governmental funding for health care initiatives, attracting foreign investments and trained personnel to help in health care (Rutherford, 2009). 1.3.2. Government Initiatives to promote Medical Tourism in India Medical tourism is a multi-dimensional activity, and basically a service industry. The medical tourism industry offers a high potential for India primarily because of its inherent advantages in terms of cost and quality. The Ministry of Tourism has taken several steps to promote India as a Medical and Health Tourism Destination, using promotional tools such as CDs, pamphlets and brochures. Medical tourism is being specifically promoted at international platforms like World Travel Mart, London, ITB, Berlin, ATM etc. Various road shows were conducted by the Ministry of Tourism in West Asia (Dubai, Riyadh, Kuwait and Doha) in October 2009 as part of promoting medical tourism. In the same year, to provide financial assistance to health providers, the Ministry of Tourism launched a scheme called Market Development Assistance. The Indian Institute of Travel and Tourism Management, Gwalior, conducted a study focusing on the problems and challenges faced by medical tourists visiting India. To focus on the problems of Medical tourism, the ministry also has published a book named, '5 Challenges of Medical Tourism in "Vulnerable" India'. The Indian Ministry of Tourism has also started a new category of visas for medical tourists called 'medical visas'. Further, efforts have been made to improve the basic infrastructure including aviation sector to ensure the smooth arrival and departure of health care seeking tourists. It would be necessary that all wings of the Central and State governments, the private sector and voluntary organizations become active partners in the endeavor to attain a sustainable growth in tourism if India is to become a world player in the medical tourism industry (Sharma 2013).A few individual hospitals in India have their own websites to assist the tourists coming to India for treatment, but are not as vibrant as in the case of Thailand and Malaysia where websites are a marketing strategy of the governments to boost the number of inbound medical tourists (Ricafort, 2011; Mun et al, 2014). The Ministries of Tourism, Health and Family Welfare, Government of India, are evolving an approach, as a strategic push, to open up the Indian healthcare CESS Monograph - 42 14 sector to foreign tourists. To ensure the quality of healthcare services, the Ministry of Health and Family Welfare has set up a National Accreditation Board for Hospitals, under the Quality Council of India for accreditation of hospitals (Mishra, 2014). Visa: A special visa called 'medical visa' was introduced in India in 2005 with a view to facilitating the international patients visiting India for treatment. The visa is valid for one year and requires the patient to register with the Foreigner Regional Registration Office within two weeks of arrival.This sometimes does not go down well with people having serious issues (Times, 2013). Sharma opines that tourists should be granted a quicker visa or visa on arrival so that they can make hassle-free travel and can contact the Immigration Department at any point of entry for a quick clearance. There is also a need for developing supporting infrastructure such as transport, accommodation, and communication and information channels to facilitate medical tourism(Sharma, 2013). Recently, in the SAARC summit, Prime Minister Narendra Modi made an announcement that an immediate visa would be provided to patients from South Asian Association for Regional Cooperation (SAARC) countries. This is expected to give a huge boost to medical tourism in India as a large number of patients from the SAARC countries come to India for treatment. Medical excellence has always attracted patients from different countries to India, but cumbersome visa rules have always diverted patients to other countries like Malaysia, Thailand and Singapore (Times, 2014). In Malaysia and Thailand, visa rules are easy and flexible for foreign patients who seek treatment and can be extended, if necessary, from 30 days to 90 days. The facility also allows for four persons to accompany the patient with the same visa conditions (Mun et al, 2014). Marketing of Medical Tourism Services: Marketing of hospital services are done through websites and advertisements in in-flight magazines. Hospitals attract international patients with representative offices or agencies in other countries. For example, hospitals in Singapore also set up offices such as in Indonesia or the Middle East. These agents help establish and maintain relationships such as with local hospitals, doctors, embassies, sponsor corporations, or insurers. Participating in different events also facilitates such relationships. For instance, trade shows, exhibitions or training seminars allow healthcare providers to share their medical expertise, while longer-term physician exchanges may also be organized in alliance with medical university. An initial diagnostic report by the hospital concerned should be enough for issuing a medical visa, or may be issued by a report of the public health authority of the tourists' home country (Babu and Swamy, 2007). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 15

1.3.3a. Contribution of Medical Tourism to the Indian Economy India is emerging as a prime destination for health and is contributing substantially to the socio-economic development of the society by enhancing employment opportunities, an increase in foreign exchange earnings and helping in uplifting the living standards of the host community through development of infrastructure and a high quality educational system. Medical tourists bring in foreign currencies and help create good jobs at hospitals. The existence of sophisticated hospitals improves the overall health care infrastructure of the country. These hospitals also help prevent first rate Indian doctors from leaving India to practise overseas and encourage those who have already left to return to India to renew their practice. The opportunity to practise western style medical care in their native India is becoming increasingly attractive. Some return because of their love for the country. Moreover, healthcare business innovations are also attracting attention. For example, Wockhardt Hospitals have pioneered a special type of heart surgery that causes no pain and does not require general anesthesia or blood thinner and puts the patients back to normal much faster than usual. These ideas not only bring medical tourists to India, but also entrepreneurs and scientists to learn and witness the new innovations (Egan, 2010). By developing the medical tourism industry, India also improves its economic position. Foreigners who receive medical services in India help the country promote itself as a business and tourism destination (Carruth and Carruth, 2010). 1.3.4 Constraints of Medical Tourism The major constraint in the expansion of Medical Tourism in India is the non-availability of adequate infrastructure facilities. There is also the scarcity of trained manpower in different healthcare sectors. There is a lack of concern for the maintenance of the standard of the facility. Lack of good language translators is another constraint in the way of promoting medical tourism. The partial attitude of the government towards corporate and public hospitals can also be a constraint in the development of medical tourism. The Government cannot neglect the role of corporate hospitals as a source of foreign exchange earnings, a provider of high class medical facilities and technology, a medium of fulfilling the demands of foreign patients. Another reason is the high service tax. A tourist has to spend a lot of money on availing of the tourism related services because the sales tax levied on these services is two times higher than any other developed country. Medical tourism has led to a fair growth in the private sector, but it has some adverse effects. This could lead to a situation where corporate hospitals are established using public funds and subsidies. The presence of a lengthy process of getting visa can also hinder the development of medical tourism (Sharma, 2013; Anvekar, 2012; Hazarika, 2010). CESS Monograph - 42 16

Even after the treatment when patients go back to their country, a proper follow-up care may not be possible which may lead to infections and further complications (Lori, 2008; Turner, 2011). There is a practice among the hospitals in India of raising their fees frequently which may not go down well with the international patients. Some unethical professional practices also discourage patients from coming to India. More and more hospitals should start taking accreditations in order to ensure a steady flow of foreign tourists in to the country. Also, there is no proper coordination between the travel industries and the medical fraternity (Roy, 2008). The study by Saravana and Krishna Raj using secondary data and reports, however, indicate a significant growth of medical tourism which is also complementing the growth of hotel and travel industry business in India. At the same time, there is an increase in medical costs for local people (Saravana and Krishna Raj, 2015). Some of the American policies, like the signing of the Patient Protection and Affordable Care Act (PPACA) into law in March, 2010 aimed at increasing access to health care and reducing the cost of treatment, discourage patients from going out of the country for treatment. This, in turn, affects medical tourism in India (Yang, 2011). 1.4. Reasons for Medical Tourism Medical Tourism is also called health tourism and wellness tourism. It is a combination of two services-Healthcare and Tourism. It usually involves the movement of people from the developed countries for medical purposes as well as for visiting various tourist places. People travel to other far of countries in search of high quality treatment at a relatively lower cost and the other reason is that they don't have to wait for long. Medical tourists are usually from industrialized countries like the USA, Canada, Great Britain, Western Europe, Australia and Middle East. But more and more people from many other countries of the world are also seeking out places where they can both enjoy a vacation and access medical treatment at a reasonable price. This has become a highly profitable industry. And this may be due to many reasons like high cost of medical procedures, large number of uninsured and under insured people in the developed nations as well as high insurance premiums. This may also be because people don't want to wait long for treatment in their own country. Internet and different communication channels in most of the developing countries also help the patients know about the availability of high quality healthcare services at affordable rates. Cheaper air fares may also help the medical tourism industry. Some patients also travel for medical treatment because the procedures they want are not available in their own country. Protection of Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 17 privacy and confidentiality may be another reason for which people travel to other countries. Patients, who want procedures like plastic surgery, gender change procedures and drug rehabilitation, expect their privacy to be safeguarded. Finally, some patients have medical care abroad for the opportunity to travel to exotic locations and vacation in affordable luxurious surroundings. Many immigrants may also seek medical treatment abroad in the place of their origin (Babu and Swamy, 2007; Bies and Zacharia, 2007; Carruth and Carruth, 2010; Shanmugam, 2013; Giacalone, 2011). One of the main reasons for medical tourists coming to India is the highly advanced medical facilities available in India. Indian hospitals have a very skilled medical manpower, high technology with doctors bringing in their specialized training and knowledge from Western countries. A study conducted by Reddy among 32 respondents shows that the most important factor behind medical tourists coming to India is the expertise doctors possess and world class facilities available in Indian hospitals. Affordability is another important factor contributing to medical tourism (Reddy, 2013). 1.5. Medical and Travel Expenses of Tourists Globalization and development in information technology have led to the spread of medical tourism. This type of health care may be a cost effective alternative for many medical procedures. The medical services which were available only in the U.S.A and other developed countries are now available in many developing countries. Thus, patients from highly industrialized countries look for medical services in less developed countries. The main reason for this is the prevalence of low costs. These patients may be people who are uninsured or underinsured belonging to the middle class. They may require medical procedures which are not covered by their insurance and they have to pay out of their pocket for their health care (Carruth and Carruth, 2010). 1.5.1. Cost Comparison Medical Tourism has become a major force behind the growth of service exports worldwide with India and Thailand occupying the major global market. Hospitals offer package deals for standard procedures which may be less expensive. U.S Health care costs have become exorbitant due to bureaucracy and expensive medical malpractice insurance. The cost advantage is regularly mentioned in the US health reform debate as being one of the means to keep US health spending from getting out of hand. Even those with health insurance cannot afford treatment that is not covered under their insurance plan. The cost of treatment in countries like India, Mexico, and Thailand is as less as one- tenth to a quarter of what it is in the United States (Piazolo and Zanca, 2011;Roy, 2008). CESS Monograph - 42 18

Currently, there are a number of medical tourist destinations worldwide which offer excellent medical treatments that cost only a fraction of the total health care expenses. Medical care in countries like India, Thailand, and Singapore can cost 10 percent of the cost of comparable care in the United States. In Thailand, for many medical tourists, the main attraction is the low price of treatment. And because of this, medical tourists tend to choose a different country for their treatment and to enjoy a luxury vacation as well (Ricafort Kristine Mae, 2011). The growing importance of medical tourism in India is thus, due to the cost of medical treatment which is comparatively 40% less than what is offered by other developed countries. While a cardiac patient has to pay US$ 40,000 - 60,000 in the United States, US$ 30,000 in Singapore, US$ 12,000 - 15,000 in Thailand for treatment, the same treatment can be availed of in India for only US$ 3,000 - 6,000 (Bhangale, 2008; Joseph, 2013; Prakash Nanita Tyagi Monika, 2011; Sharma, 2013).

Table 1.4: Cost Comparisons (US$) Medical Procedures USA India Thailand Singapore Malaysia Mexico Costa Rico Heart Bypass 133000 7000 22000 16300 12000 27000 24100 Heart Valve Replacement 140000 9500 25000 22000 13400 30000 30000 Hip Replacement 57000 7020 12700 1200 7500 13900 11400 Knee Replacement 53000 9200 11500 9600 12000 14900 10700 Face Lift 16000 4800 5000 7500 6400 11300 4900 Laparoscopy Gastric Bypass 52000 9300 13000 16500 12700 11000 n/a Source: Medical Tourism in India, Madras School of Economics, 2013 1.5.2. Medical Tourism Insurance In the developed countries like the USA, medical Tourism started as an option to those who were not having insurance and who were willing to pay out of their pocket to travel to other country with a view to saving significant amounts of money as compared to the cost of treatment in their countries. Today, employers and health care insurance companies look for less costly treatment in other countries for their employees. The insurance industry has become an active participant in medical tourism. Many U.S. companies have initiated policies with out-of-country travel options in their health insurance plans. For example, West Virginia has considered legislation that provides for financial incentives to state employees willing to travel outside of the United States for health care. In several states, Blue Cross Blue Shield sells insurance policies that enable or encourage patients to access expensive surgical procedures at low-cost offshore medical facilities. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 19

For example, Blue Cross of South Carolina allows treatment at the Bumrungrad International Hospital in Thailand. Some hospitals have sought out companies such as Healthbase, which work with overseas medical providers in arranging for U.S. citizens to travel abroad for availing of health care. U.S. hospitals see the potential to attract individuals from other countries such as Canada to the U.S., to pay out of pocket for certain medical procedures (Carruth and Carruth, 2010). Medical tourism has led to the development of many businesses and industries both within the country patients belong to and also the country to where they go for treatment. Some insurance companies in the developed countries offer discounts to patients willing to go abroad for treatment. For instance, in 2006, Blue Ridge Paper Products Inc, a company based in North Carolina, gave incentives to its employees to travel to India for undergoing non-emergency surgeries. As a self-insuring American company, White Hill Paper Products Inc. from North Carolina provides its employees with a medical incentive plan that includes bonus, extra sick leave, and coverage of air fare, if its employees choose to have their non-emergency surgeries done in , India (Reddy, 2013; Sharma, 2013). 1.6. Quality of Health Care The quality of a hospital can be judged by the advanced medical technology and quality treatment in the international hospitals. Generally, the medical care in hospitals is better if the medical technology is more up-to-date. As a result, many hospitals try to advertise the availability of their advanced devices for surgical treatments in their hospitals. For example, Apollo, Hyderabad, promotes its PET/CT scans devices (Yang, 2011). 1.6.1. Quality and Safety Concern Quality and safety concerns are most important for patients who opt for medical treatment in another country. When patients choose other countries, they don't just consider the price, but also the quality of medical care that the international medical facilities provide because medical standards may vary from country to country. Medical care organizations usually give a fair assurance of quality and safe medical treatment and care (Giacalone, 2011). At the pre procedure stage, customers are more concerned with the quality of treatment, connectivity, cost of treatment, ease of access and of purchase. The quality of treatment may include the specialization and competence of doctors as well as of paramedical staff. Patients are also concerned with the quality medical procedure as well as of clinical and non-clinical infrastructure. How well is the medical tourism country connected to the patient's own country may also be looked into before planning the treatment. Less CESS Monograph - 42 20 time to wait for treatment and how easily visa is available are also matter of concern for patients. A few patients may also be concerned with other factors that facilitate purchase like insurance, terms of payment and help in finalizing the travel itinerary. After the treatment, the hospital also makes sure that the patients return to their home country safely (Prakash et al, 2011; Giacalone, 2011). 1.6.2. Qualification of Medical Staff The most important factor for patients who come in for medical treatment from different countries is the competence of doctors. Having specialized and qualified doctors and staffs gives a competitive advantage for the hospital concerned. In fact, most of these doctors in the host countries are trained in the United States with specialization degrees from reputed medical universities of the U.S. (Dawn and Pal, 2011). Some internationally accredited hospitals in Thailand, like the Bumrungrad International Hospital, SamitivejSukhumvit hospital and Bangkok Hospital Medical centre, provide quality healthcare at affordable rates. These hospital also have physicians trained at major medical centres in the US and Europe (Ricafort Kristine Mae, 2011). A strategy that Indian Health care service providers use to attract international patients is its well-trained medical specialists who have qualified from well-known overseas institutes. Medical professionals affiliated to the recognized accredited hospitals hold a very strong reputation in their respective fields of specialization. Big hospitals in India also have good infrastructure with luxurious and spacious rooms. This is an added advantage when it comes to drawing international patients to Indian hospitals (Dawn and Pal, 2011;Roy, 2008). 1.6.3. Accreditation of Hospitals Hospital accreditation is a type of quality assurance process under which health services provided by hospitals are evaluated by an external body for determining whether applicable standards are complied with. An accredited hospital raises the confidence level of the patient. Although it is not the only determining factor in itself, it ensures that all hospitals and healthcare providers maintain a fair quality treatment. The U.S. based Joint Commission International (JCI) is a dominant organization with respect to international accreditation of hospitals. The label is to signal that an accredited hospital offers an internationally recognized level of treatment. Degrees, fellowships at elite institutions, and the U.S. board certification are used for promoting professionalism among physicians employed by international hospitals. Partnerships with elite organizations such as Harvard, John Hopkins, and Mayo Clinic confer instant status and brand name recognition. The Wockhardt hospitals throughout India have the "Harvard" tag attached Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 21 to them. Also symbols of advanced biomedical technologies convey that hospitals have top-tier health care. Some important international accreditation bodies such as the International Society for Quality in Health Care (ISQUA), the National Committee for Quality Assurance (NCQA), the International Organization for Standardization (ISO), and the European Society for Quality in Healthcare (ESQH) are also trying to ensure the quality of medical services through their accreditation processes (Lori, 2008; Turner, 2011). Thailand was the first country in Asia to have achieved the JCI accreditation in 2002. Currently, there are 14 hospitals in Thailand accredited by JCI which aims to continuously improve the safety and quality of health care to the international standards. In Malaysia, there are 13 private healthcare facilities which have obtained the JCI accreditation with 10 of them also having obtained the Malaysian Society for Quality in Health (MSQH). Singapore with 21 JCI accredited hospitals endeavors to provide a top healthcare delivery system (Mun et al, 2014; Ricafort Kristine Mae, 2011). In India, in the recent times, a number of smaller healthcare providers have been working in collaboration with the government as part of launch of a comprehensive programme to promote medical tourism. These include putting in place an accreditation system for domestic hospitals and healthcare providers. Quality Council of India (QCI), an organization of Government of India, set up National Accreditation Board for Hospitals and Healthcare Providers (NABH) in the year 2006. In NABH accredited hospitals, there is a strong focus on patient rights and benefits, patient safety, control and prevention of infections besides practising good patient care protocols like special care for vulnerable groups, critically ill patients and better and controlled clinical outcomes. Developing of a fixed price for super specialty services offered by Indian hospitals, adoption of country- specific marketing strategies, opening of overseas facilitation centers and tie-ups with overseas insurance companies are also used for promoting medical tourism. There are 21 JCI accredited and 63 NABH accredited healthcare providers in India (Devrath, 2011; Joseph, 2013). 1.7. Ethical Issues The very idea of Medical Tourism that a tourist travels from a rich country to a poor country with a view to exploiting the resources leads, in the process, to the rise of various ethical issues. It includes using body parts from local people which have been either purchased or taken from them. The history of research ethics begins with the tragic history of research abuse by the Nazi doctors during the World War II. Although research continues to successfully CESS Monograph - 42 22 expand our scientific knowledge frontier and medical capabilities, the actions of Nazi physicians during the World War II put ethical considerations of human research into the forefront of public debate/discourse. During the World War II, a series of human experimentation was conducted on a large number of prisoners, mainly Jews from across Europe and disabled non-Jewish Germans by Nazi Germans in their concentration camps. The prisoners were forcibly subjected to harsh conditions and trials to test the limits the human body could withstand, or often to simply inflict as much pain as possible which typically resulted in death, disfigurement or permanent disability. The Nuremberg Code of 1947 is often considered the first document to have set out an ethical regulation of human experimentation. According to this, the subject must give an informed consent; there must be a concrete scientific basis for the experiment; and the experiment should yield positive results that cannot be obtained any other way (Jonathan, n.d.). The buying and selling of organs in the global market has become an ethical issue for transplant clinicians everywhere in the world. At the Second Global Consultation on Human Transplantation of the World Health Organization (WHO) in 2007, it was brought out that organ trafficking constituted 5-10% (estimated) of kidney transplants performed annually throughout the year. Rich patients travel from one country to another for purchasing kidney or liver mainly from poor people (Budiani-Saberi and Delmonico, 2008). Even physicians, who have no part in the , have to bear the responsibility for those recipients, who return to their home country after , with unknown vendors. These vendors or commercial living donors resort to organ sale because they don't have any other means to support themselves and their families. In some of the countries with weak regulatory mechanisms like India, Iran, China, Pakistan, Philippines, Brazil, Turkey, Moldova, Ukraine, Russia, Bulgaria, and Romania, there exists a large scale organ trafficking. The World Health Organization identifies Colombia, India, Pakistan and the Philippines as the leading global hot spots for buying and selling of human organs (Turner, 2008). In China, 90% of the transplanted organs are from executed prisoners. This may have led to an increase in the death penalty instead of long custodial sentences. This is because providing organs results in high financial rewards. However, after Istanbul Declaration, which condemned transplant tourism, China has stated that Chinese citizens will be a priority for organs. In the United States, the high demand for and poor supply of kidneys has resulted in many patients travelling abroad for transplant surgery (Huang et al, 2008). The Philippines is establishing itself as a leading global destination site for commercial sale of human organs (Turner, 2008). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 23

According to World health Organization (WHO,2012), approximately 66,000 kidney transplants, 21000 liver transplants, and 6000 heart transplants were performed worldwide in 2005, whereas, a global increase in kidney diseases and a diminishing supply of kidneys have contributed to a growth in illegal kidney trade. In the Indian context, a thriving black market facilitates the expansion of transplantation tourism. In 2008, a black market transplant racket was busted that had been harvesting kidneys from poor laborers, sometimes against their wishes, and using them for transplantation on foreign patients. There are also cases of organ theft, where people were misled in to believing that they needed a small operation, during which one of their kidneys was removed. Also the Indian who conducted the operation and oversaw the surgery did not have any medical training. Moreover, in a number of cases, instances of death or serious complications like HIV infection, hepatitis, and recipient mortality after transplantation have been reported. In some cases, the donors are reported to have regretted their act, besides expressing feelings of social rejection, discrimination and depression. Moreover, research on organ selling indicates that when individuals sell a kidney, they usually receive substandard medical care following nephrectomy, experience no long-term economic benefits, suffer a decline in self-assessed health status and do not receive the sums promised in exchange for selling a kidney. The legalization of selling one's organs could let the patient live longer, while the sellers have the freedom to do as they please with their bodies without harming others (Smith, 2012; (Turner, 2008). The multi-billion rupee Gurgaon kidney scandal came to light in January 2008, when police arrested several people for running a kidney transplant racket in Gurgaon, India. Kidneys from many victims, mostly poor hailing from nearby western , were allegedly transplanted on to clients from United States, United Kingdom, Canada, Saudi Arabia and Greece(Times, 2012). Kidney transplantation in another country also has other complications. Another ethically problematic phenomenon which is emerging is reproductive medical tourism. This may include many assisted reproductive technologies (ARTs) including invitro fertilization (IVF), Intra cytoplasmic sperm injection (ICSI), pre-implantation genetic donation (PGD), gamete donation and surrogacy. Tourists opting for reproductive medical tourism are usually from high income countries with a desire to have a child who is genetically their own. The reasons for this may be the non availability of services in the home country or the availability of low cost of the service in India. Commercial surrogacy in some countries like Australia and United Kingdom is prohibited which may be the reason behind some persons opting for surrogacy in countries where laws are more lax, like India, Thailand and Ukraine. Surrogate mothers are usually from low income countries whose main motivation may be financial. Also, in some cases, a sense CESS Monograph - 42 24 of altruism may be involved, particularly in countries like India. India is one of the world's greatest providers of surrogate mothers. However, issues like exploitation of women, welfare of children produced through the procedure and an unregulated way of handling things have been a source of concern. Media reports suggest that surrogate mothers may be sometimes accused of adultery and may be ostracized by the community. Considering this risk, an informed consent of the potential surrogate mother is necessary. Moreover, it is also a concern to see to what extent the health of the surrogate mother is maintained beyond her gestational role. The surrogate mother's health, even after the delivery, is a source of concern which may include post partum injury or depression (Deonandan, 2013). In the absence of any legal safeguard, many children born out of surrogacy are left to die. It is a common practice that the commissioning parents fail to take responsibility for children if they do not suit their needs, mostly in the case of children who are born with some abnormalities. And the risk of congenital defects in children born through ART is twice as compared to natural births. The decision of an Australian couple to abandon one of the twins born out of surrogacy has highlighted the need for a mechanism to regulate reproductive medical tourism (Times, 2014). 1.8. Need for the Study India offers world class health care that costs substantially less as compared to developed countries. It uses the same technology used by the developed countries with specialists attaining similar success rates. There is a need to identify the role of various partners involved in promoting healthcare. Moreover, it is necessary to create an effective environment and network. Keeping these factors in view, the present study was conducted across three cities in India-Hyderabad, Chennai and Mumbai. 1.9. Objectives of the Study This study is commissioned to explore medical tourism within the framework defined by its specific objectives. The specific objectives of this study are: ● To understand the background characteristics of foreign tourists seeking medical care; ● To know the reasons for choosing India for medical tourism and sources of information; ● To study the details of their medical and travel expenses; ● To understand their perceptions regarding the quality of care, availability of translators, availability of care takers and ethical issues involved. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 25

2. Methodology

India is a country known for its lavish treatment of all visitors, no matter where they come from. Its visitor-friendly traditions, varied life styles and a rich cultural heritage and colorful fairs and festivals hold an abiding attraction for tourists. Medical services in India are particularly affordable, with low prices compared to many developed coun- tries. Factors such as low cost, scale and range of treatments provided in the country add to its attractiveness as a medical tourism destination.

2.1 Location of the Study Area The study is commissioned to explore medical tourism in three metropolitan cities -- to understand the background characteristics of medical tourists visiting India for treat- ment; the reasons for their choosing India for treatment and their perceptions regarding the quality of care as also the ethical issues involved in medical tourism as reported in media.

The study covered 3 cities, 1 each from 3 states--Hyderabad, Chennai and Mumbai - from Andhra Pradesh, Tamil Nadu and Maharashtra respectively. The three metropoli- tan cities of Hyderabad, Chennai and Mumbai were selected for the study because of a large number of foreign patients coming to these cities for treatment. The three cities are well connected to various global destinations, thus making it a convenient option for people from other countries to combine medical care with recreation. The hospitals here are well equipped with modern amenities and medical professionals who are highly qualified.

Sampling: Originally, it was planned to draw a sample of 50 foreign patients from 5 hospitals in each selected city for the present study. But due to certain limitations, more hospitals had to be taken into consideration in Hyderabad and Mumbai. There was no continuous flow of foreign patients to hospitals. Hence, patients were approached as and when they came. In a few cases, in the midst of data collection from patients, the hospital administrators were reluctant to cooperate. The details of sampled hospitals from three cities are given in Tables 2.1,2 &3. CESS Monograph - 42 26

Table 2.1: Details of Sample in Three Cities Sl No. Name of States Name of cities No. of Hospitals No of patients 1 Andhra Pradesh Hyderabad 7 54 2 Tamil Nadu Chennai 4 50 3 Maharashtra Mumbai 8 50 Total 19 154

Map 2.1: Location of study area

The study was conducted in three cities of India ---- Hyderabad, Mumbai and Chennai (Map 2.1). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 27

Map 2.2: Andhra Pradesh

a) Hyderabad Hyderabad, the capital city of Andhra Pradesh (now Telangana), is a city endowed with a rich heritage and culture. World class medical services at affordable rates are available in Hyderabad. The hospitals are well equipped with modern amenities and medical professionals who are highly qualified. The hospitals employ qualified translators through- out the day so as to ease the language troubles faced by visitors. There is no waiting period in hospitals as you can get treatment immediately, without having to worry about insurance issues. The study was conducted across 7 hospitals in Hyderabad. List of hospitals in Hyderabad 1. Basvatarakam Indo American Cancer Hospital and Research Institute 2. L.V. Prasad Eye Institute 3. Krishna Institute of Medical Sciences 4. Kamineni hospitals 5. CARE 6. Continental hospitals 7. Asian Institute of Gastroenterology CESS Monograph - 42 28

Map 2.3: Tamil Nadu

b) Chennai Chennai, known as the health care capital of India, attracts about 40% of the country's medical tourists with more than six lakh tourists visiting the state every year, according to a study by Confederation of Indian Industries (CII).It has a large number of hospi- tals with latest medical equipments and facilities, dedicated doctors, treatment expertise of international standard, all at low costs. Four hospitals were covered in Chennai. List of hospitals in Chennai 1. Fortis Malar Hospital 2. Global hospitals 3. SriRamachandra Medical Center 4. Billroth Hospital Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 29

Map 2.4: Maharashtra

c) Mumbai Mumbai, the capital city of the state of Maharashtra, is one of the biggest cities in India. The city is the centre of all the businesses and medical activities in the country and can be considered an ideal destination for medical tourists around the world. Mumbai medical tourism boasts of highly qualified medical professionals and advanced medical facilities along with a wide range of tourist destinations. Eight hospitals were covered in Mumbai. List of hospitals in Mumbai 1. Asian Heart Institute 2. Hinduja Hospital 3. Nanavati Superspecialty Hospital 4. Cumballa Hill Hospital and Heart Institute 5. Jaslok Hospital 6. Global Hospital 7. Kokilaben Dhirubhai Ambani Hospital 8. S.L.Raheja CESS Monograph - 42 30

Table 2.2: Selection and Sample S. No Sample Unit Description No. of Units Remarks 1 State 3 Andhra Pradesh, Maharashtra, Tamil Nadu 2 Cities 3 Hyderabad, Mumbai, Chennai 3 Hospitals 19 Initially it was decided to collect data from 5 hospitals from each city. Since the required number of patients was not available with the selected hospitals for various reasons, more than 5 hospitals were visited in the study cities. 7 hospitals were visited in Hyderabad, 4 hospitals from Chennai and 8 from Mumbai. 4 Foreign patients 154 Data was collected from 54 patients in Hyderabad, 50 in Chennai and 50 in Mumbai.

2.2 Data Collection A field survey was carried out at selected hospitals in Hyderabad, Chennai and Mumbai. Three types of questionnaire were prepared - one for international patients, one for the hospital and an observation tool for each hospital. A questionnaire was prepared to be administered to international patients. A hospital questionnaire was administered to the hospital staff to get information about each hospital. The survey was conducted in three cities. We started the survey from Hyderabad. Although we visited 15 major hospitals in Hyderabad, actual data collection was done from 7 hospitals. Secondary data was gathered from documents, research journals, business periodicals, newspapers, websites and government releases. A pilot study was conducted in two hospitals in Hyderabad before taking up the final study. In the primary field survey, following questionnaires were used: a) Foreign Medical patients/tourists questionnaire Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 31

Table 2.3: Details of the sampled hospitals. S. No State Cities Hospitals Foreign Patients 1 Andhra Pradesh Hyderabad 1. Basvatarakam Indo American Cancer Hospital and Research Institute 2. L.V. Prasad Eye Institute 3. Krishna Institute of Medical Sciences 4. Kamineni hospitals 5. CARE 6. Continental hospitals 7. Asian Institute of Gastroenterology 54 2 Tamil Nadu Chennai 1. Fortis Malar Hospital 2. Global hospitals 3. SriRamachandra Medical Center 4. Billroth Hospital 50 3 Maharashtra Mumbai 1. Asian Heart Institute 2. Hinduja Hospital 3. NanavatiSuperspecialty Hospital 4. Cumballa Hill Hospital and Heart Institute 5. Jaslok Hospital 6. Global Hospital 7. KokilabenDhirubhaiAmbani Hospital 8. S.L.Raheja Hospital 50 b) Hospital Questionnaire c) Observation tool 2.3 Questionnaires for Primary Data Collection Questionnaire was designed to obtain information from international patients. During preparation of these tools, the insights from review of literature, secondary data and discussions with international patients during a pilot study were immensely useful. The foreign patient questionnaire was divided into five sections. The first section was about the background characteristics of patients including their sex, age, information about family members, the country they belonged to, their address and the health problems they were suffering from. The second section was to learn about the reasons for which they choose India for treatment, the difficulties they faced in their country, and visa related questions. The third section was to look into the medical and travel CESS Monograph - 42 32 expenses of patients. The fourth section was to gather information about interpreters/ translators. And the last section was meant to probe the quality of care in hospitals and the satisfaction level of patients with respect to medical services provided. A hospital questionnaire was administered to hospital personnel (Manager, International Patient Care Unit) to have an idea about the hospital concerned like the number of doctors, nurses, paramedical staffs, beds and other facilities. The observation tool is the investigator's observations related to the hospital. 2.3.1 Foreign Patient Questionnaire A questionnaire was prepared to be administered to international patients. The following were the major sections included in the questionnaire for foreign patients. 1. Background Characteristics a. This section included the patients' name, sex, age, family background, name of the country they belonged to, and the health problems they were suffering from. 2. Reasons for coming to India a. Questions like why they chose India, who suggested a particular hospital, how they contacted the hospital, the facilities that attracted them, the difficulties faced in their country, and the problems, if any, they faced while getting visa. 3. Medical and Travel expenses a. This section included questions like whether they had health insurance, the cost of their treatment and stay, were they planning to do some tourism and the cost of their entire trip to India. 4. Availability of translators/Interpreters. a. This section included questions like whether the international patient was facing any problem with language and whether the hospital was providing translator/ interpreter. 5. Quality of care a. This section included questions like the patients' satisfaction level, whether they were satisfied with the treatment and overall stay in the hospital, their views about food served in the hospital, and cleanliness and hygienic condition of the hospital. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 33

2.3.2 Hospital Questionnaire A questionnaire was prepared to be administered to the hospital personnel. The questionnaire included general information about the hospital. The major sections were as follows: 1. General information like the name, whether the hospital was general or special in nature, whether private or public and whether the ownership type was corporate, trust or proprietorship. 2. Facilities This section included the number of doctors, nurses, paramedical staff, departments, different facilities like outpatient and inpatient services, educational and research facilities, and other public facilities like cafeteria, pharmacy store etc. 3. Exclusive wing for medical tourists This section tried to have an idea about the facilities offered by the hospital for foreign patients. 4. Countries from where most foreign patients were coming 5. Special services provided by the hospital 6. Procedures the medical tourists opted for 7. Average number of medical tourists 8. Average age of medical tourists 9. Details of the medical record system of the hospital. 2.3.3 Observation Tool This was to assess the actual situation in the hospital. This included the following questions. 1. Name of the hospital 2. Date of visit 3. Details about help desk 4. Separate desk for international patients 5. Procedure of meeting the doctor 6. Information about waiting room 7. Approach to the person concerned 8. Treatment by the staff 9. Cleanliness and hygiene of the hospital CESS Monograph - 42 34

10.Different treatment for international patients 11.Availability of drug store 12.Availability of cafeteria 2.4 Pilot Study After the questionnaires were prepared, a pilot study was conducted in two hospitals in Hyderabad- ● Basavatarakam Indo American Cancer Hospital & Research Institute ● CARE Hospital On the completion of a pilot study, the questionnaires were revised based on the inputs received from the field. The data collection process started in Hyderabad from 23rd of January, 2014. Although we got permission from a few hospitals immediately, enough patients were not there. So we had to wait and approach the patients as and when they came. Moreover, due to Ramjan, very few patients were coming for treatment. Iraq war and the advent of Ebola virus (according to some hospital administrators) were the reasons for our finding a very few international tourist patients. Finally, 54 international patients were approached in Hyderabad and the data collection completed by September, 2014. In Chennai, three hospitals immediately granted permission to talk to the international patients admitted in their hospital. The data collection in Chennai was started in June, 2014 and information was collected from 32 patients. But thereafter, none of the hospitals was willing to grant us permission, while a few hospitals didn't have international patients admitted during that period. Finally, in May 2015, we were granted permission to approach 18 more international patients and we managed to complete the data collection. It was very difficult to get permission for approaching the international patients in Mumbai. We tried to take permission over the phone, but none of the administrators was willing to grant us permission. All the same, the data collection was started in October, 2014. But in the first attempt, only 9 questionnaires could be filled up. Due to heavy rains, it was difficult to commute in Mumbai. Finally, in July, 2015 we were granted permission by a few more hospitals in Mumbai and the data collection was completed thereafter. 2.5 Limitations Several limitations impeded the progress of this research. ● Although several hospitals are promoting medical tourism in the three cities chosen, very few of the administrators were enthusiastic about granting permission to interview Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 35

their patients for this research. Permission requests were made to many hospitals in 3 cities, but finally, only 7 from Hyderabad, 4 from Chennai and 8 hospitals from Mumbai, granted permission for interviews. ● In most hospitals, the administrator of first contact was the director or the lead person in charge of international patient services. Several of the facilities took several months to review the application for permission, but ultimately chose not to grant permission. For nearly every single rejection, follow up had to be done with the administrators on multiple occasions. ● There were also several challenges associated with the hospitals that granted permission. Administrators in some hospitals spoke of getting a large number of foreign patients. One administrator specifically mentioned that they received approximately 50-60 foreign patients every month from all around the world. However, when requested for interviewing a few of their patients, the administrator was non-committal. The investigator was told to call the administrator on a given day to see if any patients were available for interviewing, but when called, the administrator asked us to call back another day. When called again, the administrator had a reason for not allowing any interviews, or in some cases, allowed to interview only one or two patients at the most. ● One of the hospitals in Hyderabad, a maximum number of international patients come for treatment, refused to give permission, as part of its policy, to talk to their patients. ● On multiple occasions, the administrators mentioned that protecting the privacy of their patients was very important. Several administrators also mentioned that many of their patients had not yet recovered enough from their surgeries/treatments and that they could not be disturbed for this research. Administrators also wanted privacy for the hospital. ● The administrator claimed that anything perceived as negative regarding their hospital might have an impact in terms of attracting foreign patients which was already challenging enough. Anonymity is assured for both the facilities and the patients. None of the administrators would grant permission to examine hospital records regarding the number of patients who travelled to their hospitals and other demographic data. ● In Hyderabad, a major problem was and is during the month of 'RAMJAN', when the number of patients is very few. CESS Monograph - 42 36

● Another hindrance towards the end of the study was due to the advent of 'EBOLA VIRUS', because of which many hospitals and even the government restricted the incoming of patients from many African countries. ● According to administrators in some hospitals, the ongoing Iraq war may be one of the reasons behind a decrease in the number of incoming patients. ● Administrators may have been hesitant to grant interviews because of privacy concerns of both the hospitals and patients. ● In Mumbai, during the last leg of data collection, it was difficult to commute because of heavy rains. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 37

3. Medical Tourism in Hyderabad

3.1: Introduction The state of Andhra Pradesh (prior to reorganization), situated on India's southeastern coast, is one of the most highly populated states in India mainly due to the development and its location near the sea coast. The state has grown in terms of its technological infrastructure and is among the major states that house sectors like IT and Telecom. It is spread over an area of 275045 sq km (Map 3. 1). Map 3.1: Andhra Pradesh Map CESS Monograph - 42 38

3.1.1: A Demographic Profile of Andhra Pradesh As per 2011 Census, the total population of Andhra Pradesh is 84,580,777 of which male and female are 42,442,146 and 42,138,631 respectively. Andhra Pradesh has a population density of 308 per sq kilometer, which is below the national average of 382 per sq Km. The literacy rate in the state is about 67.02%, of that male literacy stands at 74.88% while female literacy at 58.68%. The sex ratio is 993 females for each 1000 males, which is below the national average of 940 (Table 3. 1). The morbidity rate of the state is higher for both the sexes with the morbidity rate of males at 92 and that of female at 102. This is mainly because of the frequent occurrence of diseases like asthma, tuberculosis, jaundice and malaria (Census, India, 2011; Ghosh & Arokiasamy, 2009). Table 3.1: Demographic Profile of Andhra Pradesh Particulars Andhra Pradesh , 2011 Census Male Female Total Population 42,442,146 42,138,631 84,580,777 Density/sq Km 308 Sex Ratio 993 Literacy rate 74.88% 58.68% 67.02% Source: Census, 2011 3.1.2 Tourism in Andhra Pradesh The state of Andhra Pradesh is one of the most popular tourism destinations in India. Promoted as "Kohinoor of India", it has a variety of attractions including beaches, hills, wildlife, forests and temples. The key to tourism success in Andhra Pradesh has been its sustained marketing efforts and the creation of new tourism products. The state attracted 223518 international tourists in 2013 (Table 3. 2& Figure 3.1). Table 3.2: Foreign Tourist Arrivals in Andhra Pradesh from 2010 to 2013 Year Number 2010 322825 2011 268736 2012 292822 2013 223518 Source: Department of Tourism, Govt. of India, 2013

3.1.3: Health Care in Andhra Pradesh Andhra Pradesh is one of the first states in the country to have introduced reforms in the health sector in the 1980s. There are an estimated 21,100 private hospitals and nursing homes as compared to 300 government hospitals. While the preventive health Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 39

Figure 3.1: Foreign Tourists Arrivals in Andhra Pradesh, 2010-2013

Source: Department of Tourism, Govt. of India, 2013 services are provided by the government, the private sector plays a dominant role in providing curative and diagnostic services. The growth of private sector in the state has been phenomenal since 1980, while that of the public sector has been stagnant. In terms of types of hospitals, Andhra Pradesh has a very strong presence of the private sector in health care as compared to other southern states. The Department of Health, Medical and Family Welfare, set up in 1922, provides healthcare to the people of the state. Under the public sector, there are 4 types- sub-centres, Primary health centres, Community Health centres and District hospitals. Sub-centre, also known as sub health center, is the first contact point between the primary health care system and the community. Primary Health centre is the basic unit for providing curative and preventive health care to the population, particularly in the rural areas. Community Health Centre is the first referral unit providing referral healthcare to the cases from the primary centres. District Hospital functions as tertiary level of health care which provides curative, preventive and promotive health services to the people of the districts. The private sector plays a dominant role in providing health services in Andhra Pradesh. The private sector can be broadly divided into Non-profit and for-profit institutions. The non- profit or voluntary institutions, which are mostly found in urban areas, account for only a small share of the health care provided to the people. The for-profit providers are the major contributors to private health care services (Mallipeddi et al,2009). CESS Monograph - 42 40

A survey conducted by the government of Andhra Pradesh in 1994 shows the private sector hospitals account for around 59% of the total hospital beds in the state with 35% in the Public sector and 6% in the voluntary sector. All types of cases are being treated in a majority of the private hospitals with only a few confined to a single specialty (CESS, 2008). 3.2: Hyderabad Hyderabad is the capital city of Andhra Pradesh (prior to reorganization). It occupies 650 sq Km along the banks of the Musi River, in the northern part of the Deccan plateau. It is the capital city and also the largest city of the state of Andhra Pradesh (Map 3. 1). Map 3.2: Andhra Pradesh Map

3.2.1: Demographic Profile of Hyderabad According to 2011 Census, the population of the city of Hyderabad is 6,809,970 with 3,500,802 males and 3,309,168 females. The literacy rate of Hyderabad is 82.96% of which male literacy is 85.96% and female literacy stands at 79.79%.The sex ratio is 945 females for every 1000 males. It has a tropical wet and dry climate (Census, India, 2011). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 41

Table 3.3: A Demographic Profile of Hyderabad, as per 2011 Census Particulars Hyderabad, 2011 Census Male Female Total Population 3,500,802 3,309,168 6,809,970 Sex Ratio 945 Literacy rate 85.96% 79.79% 82.96% Source: Census, 2011 3.2.2: Tourism in Hyderabad Hyderabad was historically known as a pearl and diamond trading centre, and it continues to be known as the City of Pearls. It has a natural and sophisticated blend of old and new, an old 'Nawabi' culture with a new pro-active approach and hospitality. Hyderabad is home to a mix of Hindu-Muslim culture with a number of monuments of historical importance, including the very famous Charminar. Hyderabad has many tourist attractions, often making it difficult for tourists to set their priorities. Art lovers cannot resist the attraction of a huge repository of antiques displayed at the A.P. Museum, The Nizam Museum and the Salarjung Museum. The Golconda Fort is today very much part of the city, as is Cyberabad, a new local area created to keep pace with the zooming Information Technology and Tourism sector (Department of Tourism, GoAP, 2013). Hyderabad attracted 150745 tourists in the year 2013. However, figures from the tourism department show that foreign tourist arrivals to the city in the first two months of 2013 fell by 68 per cent as compared to the same period in 2012 (Table 3. 4, Figures 3. 2, 3.3 & 3.4). While 32,277 foreign tourists came in January and February in 2012, only 10,549 visited the city in 2013, with experts saying they were looking at a very dismal scenario in the aftermath of the Dilsukhnagar twin blasts that left 17 people dead. After a four-fold increase in the number of tourists over a nine year period from 2000 to 2009, a decreasing trend began to be seen in 2010 when the Telangana issue came to the fore. In 2012, the arrivals improved (2.92 lakh foreigners as against 2.68 lakh in 2011), but the numbers for Hyderabad continued to dip. While Hyderabad has been the major contributor to foreign tourist revenue in the state, the rest of the state, Vizag in particular, has also contributed to foreign tourist revenue in the state (Rohit, 2013).

Table 3.4: Foreign Tourist Arrivals in Hyderabad from 2010 to 2013 Year Numbers 2010 294951 2011 231503 2012 223837 2013 150745 Source: Department of Tourism, Govt. of India, 2013 CESS Monograph - 42 42

Figure 3.2: Foreign Tourist Arrivals in Hyderabad, 2010-2013

Figure 3.3:ForeignTourist Arrivals in Andhra Pradesh from 2010 to 2013

Figure 3.4: Foreign Tourist Arrivals in India from 2010 to 2013

Source: Department of Tourism, Govt. of India, 2013 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 43

3.2.3:Health Care in Hyderabad The Telangana Vaidya Vidhanparishad (after the formation of Telangana State) is a state government department responsible for administering healthcare in Hyderabad. Initially, the public healthcare system was the only main health provider, but due to a rapid growth in population, it got overburdened and as a result, voluntary organisations and small scale private enterprises entered the health care arena. The corporate sector also started since the 1980s, beginning with diagnostic facilities. Corporate hospitals have come up as chains-Medinova, Apollo, Medwin, Mediciti etc. They are financed like any other industry with a share from the promoters, banks, financial institutions, public issues. All these hospitals have received subsidies from the government in the form of cheap land and reduced duties on imports of their equipment. Hyderabad is thus served by a variety of health care providers. At the large hospital level, choices available range from the government to the autonomous, Nizam Institute of Medical Sciences (NIMS) to the corporate hospitals of Apollo, Mediciti, Medwin, etc. (Kennedy, Duggal et al, 2009). As of 2010-11, the city had 50 government hospitals, 300 private and charity hospitals and 194 nursing homes with around 12,000 hospital beds. For every 10,000 people in the city, there are 17.6 hospital beds, 9 specialized doctors, 14 nurses and 6 physicians (Table 3. 5). The city also has about 4,000 individual clinics and 500 medical diagnostic centers,which are preferred by many residents. Despite a high proportion of the city's residents (24%, according to a National Family Health Survey in 2005) being covered by government health insurance, only an estimated 28% of the population uses government facilities, mainly because of their distance, poor quality of care and long waiting periods. As of 2012, many new private hospitals of various sizes have opened or are being built. Hyderabad also has outpatient and inpatient facilities that use Unani, Homeopathic and Ayurvedic treatments (GHMC, 2011).

Table 3.5: Healthcare Facilities (Public and Private) in Hyderabad as of 2010-2011 Sl No. Healthcare/Providers in Hyderabad Numbers (2010-2011) 1 Government Hospitals 50 2 Private/Charity Hospitals 300 3 Nursing Homes 194 4 Medical Diagnostic centres 500 5 Individual Clinics 4000 6 Total beds 12,000 Source: "Government Hospitals". GHMC, 2011.Retrieved as on 9 May 2012. CESS Monograph - 42 44

3.2.4: Medical Tourism in Hyderabad Hyderabad medical tourism has become quite a success owing to the presence of many world class hospitals and experienced doctors. The city is also well connected to all the major air hubs and is thus easily accessible to tourists from all over the world. In Hyderabad, one can get world class medical services at affordable rates. The hospitals are well equipped with modern amenities and medical professionals who are highly qualified. The hospitals employ qualified translators throughout the day so as to ease the language troubles faced by the visitors. There is no waiting period in the hospitals as one can get treatment immediately. Advantages of Coming to Hyderabad for Medical Treatment ● Internationally/nationally accredited medical facilities using the latest technologies ● Highly qualified Physicians/Surgeons and hospital support staff ● Significant cost savings compared to domestic private healthcare ● Medical treatment costs are lower by at least 60-80% when compared to similar procedures in North America and the UK ● No Wait Lists ● English speaking staff ● Options for private room, translator, private chef, dedicated staff during patient's stay and many other tailor-made services ● Can easily be combined with a holiday/business trip Hyderabad receives patients from Arab and African countries and also non-resident Indians from the developed world with a majority of the international patients finding the services provided in the hospitals very good. An easy availability of certified drugs and medicines at comparatively low costs can also be a reason behind a large number of international patients coming to Hyderabad (Shaikh and Khan, 2006). 3.2.5: Accreditation of Hospitals Till recently, only a few big private health care providers were into medical tourism creating awareness in the overseas market through tie-ups with insurance companies and patient facilitation centres. However, recently a number of small healthcare providers have also joined hands with the government in promoting medical tourism (Joseph, 2013). The National Accreditation Board for Hospitals and Healthcare providers (NABH) is a constituent of Quality Council of India (QCI), established to look into the guidelines Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 45 for accreditation of hospitals and other healthcare providers. NABH is an institutional member of the International Society for Quality in Health Care (ISQua ). ISQua1 is an international body which grants approval to accreditation bodies in the area of healthcare. The approval of ISQua authenticates that NABH standards are in consonance with the global benchmarks set by ISQUA. The hospitals accredited by NABH enjoy a global recognition. This, in turn, provides a boost to medical tourism. NABH has been established with the objective of enhancing health care system and promoting a continuous quality improvement and patient safety. It provides accreditation to hospitals in a non-discriminatory manner irrespective of their ownership, legal status, size and degree of independence (NABH, 2016). A hospital willing to be accredited by NABH has to ensure the implementation of NABH standards in its organization. The standards include patients centered standards such as - access, assessment, and continuity of care, care of patients, management of medication, patient rights and education and hospital infection control. It also includes Organization Standards including a continuous quality improvement, responsibility of management, facility management and safety, human resource management and information management system (Khan, 2013). A few hospitals with NABH accreditation in India are B.M. Heart Research Centre, , Max Super Specialty Hospital, New Delhi, Moolchand hospital Delhi, Narayana Hrudayalaya, Bangalore, Fortis Hospital, Noida, Uttar Pradesh, etc.

National Accreditation Board for Testing and Calibration Laboratories (NABL) is an autonomous body under the Department of Science & Technology, Government of India. It has been established with the objective of providing Government, Regulators and Industry with a scheme of laboratory accreditation through a third-party assessment for formally recognizing the technical competence of laboratories. The accreditation services are provided for testing, calibration and medical laboratories in accordance

1 International Society for Quality assurance in Health care (ISQA was established in 1985 at Udine, Italy, in connection with a WHO working group on training in quality assurance. This was renamed as International Society for Quality in Health care (ISQua). In 1995, ISQua Secre- tariat was opened in Melbourne, Australia. It was shifted to Dublin, Ireland in 2008. ISO is an independent, non-governmental international organization with a membership of 162 national standard bodies. Its members are the foremost standards organizations in their coun- tries and there is one member per country. Each member represents ISO in its country. The member body in India is the Bureau of Indian Standards (BIS). The Central Secretariat of ISO is based in Geneva, Switzerland. Through its members, it brings together experts to share knowl- edge and to develop voluntary, consensus-based market relevant international standards that support innovation and provide solutions to global challenges. CESS Monograph - 42 46 with standards of International Organization for Standardization (ISO). ISO is an independent, non-governmental membership organization and the world's largest developer of voluntary International Standards (NABL, 2015). Apollo hospital, Chennai, was the first hospital in India to have been awarded ISO (9002) certification. Some of the NABL accredited laboratories in India include department of Microbiology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Actimus Biosciences Private Limited, Visakhapatnam, Andhra Pradesh, Aditya Birla Health Services Ltd, Pune, Alcare Diagnostic and Research Centre Pvt Ltd, Guwahati, Assam. Joint Commission International (JCI) accreditation is considered the gold standard in global healthcare. At the international level, JCI works to improve patient safety, and the quality of healthcare, through offering education, publications, advisory services and international accreditation and certification. It advocates the promotion of rigorous standards of care besides providing solutions towards achieving peak performances. This organization has been recognized by the WHO as an international regulator of patient safety(Fitterling, 2008; JCI, 2015). Some of the hospitals with JCI accreditation across the world are DRK Kliniken, Berlin, Germany, Artimis Health Institute, India, Penang Adventist hospital, Malaysia, Parkway East Hospital, Singapore, Bumrungrad Hospital, Thailand, etc. Some of the important hospitals in Hyderabad accredited by various national and international organisations are given in Table 3.6.

3.3: Hospitals Visited for the Study 1. Basavatarakam Indo American Cancer Hospital & Research Institute Basavatarakam Indo American Cancer Hospital was established in the year 2000 with some of the best cancer specialists in India. Today, it is a non-profit making organization, bestowing care and treatment on par with the world standards of excellence on everyone at affordable prices as part of proving that accessing world class treatment and facilities is as much the right of the less privileged as of those who can afford to cross the seas for a reliable and modern treatment. Besides, it has a tie-up with www.placidway.comwith a view to facilitating the international patients who come in for treatment (Table 3. 7). Accreditation:To give highest priority to quality treatment and patient safety, the institute has been accredited by ● National Accreditation Board for Hospitals & Health Care - NABH ● National Accreditation Board for Testing and Calibration Laboratories - NABL ● Standard for Occupational Health and Safety management Systems - TUV (OHSAS) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 47

Table 3.6: A List of Hospitals in Hyderabad SL. Name of Accreditation of the No. of No. of No. of Medical No. Hospital hospital beds doctors paramedical tourism staff 1. Apollo Hospital JCI, NABH, NABL, ISO 350 26 0 yes 2. Asian Institute of Gastroenterology 250 50 30 yes 3. Care Hospital NABH, NABL 430 330 220 yes 4. Fever Hospital 300 5. L.V.P Eye Institute NABH 80 40 300-500 yes 6. Prime Hospital 250 70 113 yes 7. B.I.A. Cancer NABH, NABL, TUV 450 110 115 yes Hospital & (OHSAS) Research Institute 8. Continental hospital NABH 700 80 yes 9. Krishna Institute of Medical Science NABH, NABL, ISO 1000 125 100 yes 10. Kamineni Hospital NABH, NABL 150 126 180 yes 11. Yasodha Super Speciality Hospital NABH, NABL, ISO 302 180 170 yes 12. BBR Multi Speciality Hospital 175 50 400 13. Malla Reddy Narayana Hospital 300 50 500 yes 14. Sunshine Hospitals NABH, ISO 300+ 70 yes 15. Rainbow Children's Medicare Pvt Ltd NABH, ISO 150 yes 16. Mediciti Institute of Medical Sciences 300 12 yes 17. Global Hospital, Lakdi-ka-pul NABH, NABL, HALAL 200 yes 18 Nizam Institute of Medical Sciences 946 19 Gandhi Hospital 1200* 20 Osmania Hospital 1168* Source: www.hyderabadplanet.com/Hyderabad-hospitals * based on respective hospital websites

Facilities: Number of doctors- 110 Number of nurses-301 CESS Monograph - 42 48

Table 3.7: Hospitals Visited for the Study Sl Name of the Hospital No of Observations No patients 1. Basavatarkam Indo American Cancer 11 There is an interpreter who is Hospital & Research Institute always present at the interna tional wing help desk. 2. CARE Hospital 10 3. L.V. Prasad Eye Institute 5 Most of the patients in L.V.Prasad Eye Institute are out-patients. The staff goes through the reports of pa tients', before taking them to the doctor concerned. 4. Continental Hospital 5 Along with cafeteria, there is a gift shop, a salon& spa and special dining room with food court for visiting guests. 5. Krishna Institute of Medical Sciences 10 The hospital runs a College of Nursing and College of Physiotherapy attached to it. 6. Kamineni Hospital 1 Same set of staff for the both domestic and international patients. 7. Asian Institute of Gastro enterology 12 There is a separate wing for international patients though staff is the same for both the domestic and international patients. Total 54

Number of paramedical staff- 115 Number of departments- 9 Number of specialization- 1 (cancer) Number of beds- 450 Number of inpatients- 33117/year Number of outpatients-28726/year Separate wing for International Patients: The hospital recently started a special wing for international patients with 38 beds and a team of specially trained staff. The patients Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 49 approach the senior manager, International patient Care, who refers them to the doctor concerned. Countries of International patients: The international patients are from various countries, mostly Africa (Kenya, Uganda, Tanzania, Congo, and Nigeria), Middle East, Malaysia and Bangladesh. Age of International patients: The foreign patients belong to all age groups. Average number of medical tourists in a year: The inflow of medical tourists has increased since 2010. Special services provided by medical tourism division: The hospital's medical tourism division provides special services like online counselling, Electronic transfer of medical records to and from the prospective medical tourist, arranging of a medical tourism facilitator, interpreter, and accommodation for the patients' companion. 2. Care Hospital CARE Hospitals was set up in the year 2000. The hospital provides speciality medical services in Cardiology, Cardiothoracic Surgery, Paediatric Cardiology, Paediatric Cardiothoracic Surgery, Neurology, Neurosurgery, Nephrology, Urology, etc. The in- patient services include intensive care, cardiac care, neurological care, paediatric care, medical care, as well as surgical, diagnostic and emergency services. Accreditation: The hospital has been accredited by NABL and NABH. Facilities: Number of doctors- 330 Number of nurses-750 Number of paramedical staff- 220 Number of departments- 30 Number of specialization- 26 Number of beds- 400 Number of inpatients- 400/month Number of outpatients-2000/month Separate wing for International Patients: There is no separate help desk for international patients, though it has a separate floor for foreign patients with 15 beds, 15 staff and 12 workers. The staff is specially trained to deal with international patients. The patients CESS Monograph - 42 50 are picked up from the airport with everything taken care of by the hospital staff. Countries of International patients: The medical tourists are from Africa, Middle East, Pakistan and Bangladesh. Age of International patients: The foreign patients coming for treatment belong to all age groups. Average number of medical tourists in a year: There has been a 15% growth in the inflow of international patients every year, since 2010. Special services provided by medical tourism division: Special services provided by the medical tourism division of the hospital are online counselling, electronic transfer of medical records to and from the prospective medical tourist, arranging for visa and passport, interpreter, special dietary service and accommodation for companion/s of the medical tourist. 3. L.V.Prasad Eye Institute L V Prasad Eye Institute is a comprehensive eye health facility with its main campus located in Hyderabad, India. It is a not-for-profit organization governed by two trusts: the Hyderabad Eye Institute and the Hyderabad Eye Research Foundation. The Institute is a World Health Organization Collaborating Centre for Prevention of Blindness.Its mission is to provide an equitable and efficient eye care to all sections of the society. Accreditation: NABH Facilities: Number of doctors- 40 Number of nurses- 80 Number of paramedical staff- 300-500 Number of departments- 6 Number of specialization- 1(Eye) Number of beds- 80 Number of inpatients- 60/day Number of outpatients- 800/day Separate wing for International Patients: There is no separate wing for international patients. Most of the patients are outpatients. There is only one interpreter, therefore it is very difficult to cater to all the foreign patients. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 51

Countries of International patients: Most of the foreign patients are from Africa and Middle East Countries. Age of International patients: International patients of all age groups come for treatment. Special services provided by medical tourism division: Among the special services,the hospital has only one interpreter for foreign patients. 4. Continental Hospital Continental Hospital is a super speciality hospital dedicated to excellence in medical services. It started in March 2013 with the latest global technologies in a world class environment. The year saw more than 50 international patients coming in for treatment. The hospital gives topmost priority to quality treatment and patient safety. Accreditation: NABH, JCI Facilities: Number of doctors- 80 Number of departments- 30 Number of specialization- 24 Number of beds- 700 Separate wing for International Patients: The hospital has a separate wing for international patients with a specially trained staff to handle the medical procedures. Patients of all age groups come for treatment. Countries of International patients: International patients are usually from African countries like Tanzania, Nigeria, etc., Kuwait and Uzbekistan. Average number of medical tourists in a year: The hospital received more than 50 international patients in the year 2013-2014. Special services provided by medical tourism division: The hospital provides many special services to the foreign patients like on-line counselling, electronic transfer of medical reports, arranging for visa/passport and also arranging for a tourism facilitator, tie-ups with insurance providers, interpreter, Special diet, and accommodation for companions of the patient. 5. Krishna Institute of Medical Sciences KIMS hospital has emerged as a leading multi- superspeciality hospital in a short span of time by virtue of its efficient management and a dedicated team of competent medical CESS Monograph - 42 52 professionals, working closely in association with each other in a clinically sound and technologically advanced environment conforming to quality in patient care.The hospital provides best services in patient care comparable to any international hospital of repute. Accreditation: NABH, NABL, ISO Facilities: Number of doctors- 125 Number of nurses-700 Number of paramedical staff- 100 Number of departments- 50 Number of specialization- 50 Number of beds- 1000 Number of inpatients- 400/month Number of outpatients-800/day Separate wing for International Patients: There is no separate wing for international patients. The patients are however picked up from the airport and everything from admission to discharge is looked after by the hospital staff. The foreign patients started coming in for treatment from 2012. Countries of International patients: International patients are usually from Africa and UAE. Special services provided by medical tourism division: Various special services for international patients like online counselling, electronic transfer of medical records, arranging for visa/passport, interpreter, special diet, tie-ups with travel agencies for tourism interest, and accommodation for the patients' companions are provided by the hospital. 6. Kamineni Hospital Kamineni hospital was established in 1995 with the objective of establishing it as a centre of excellence in healthcare, with accreditation granted by NABH and NABL. From one hospital to three super specialty hospitals and other diagnostic and research facilities, Kamineni has made major investments in break-through social service projects, serving people with various commercial and non-profit models. Accreditation: NABH, NABL. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 53

Facilities: Number of doctors- 126 Number of nurses- 140 Number of paramedical staff- 180 Number of departments- 28 Number of specialization- 28 Number of beds- 150 Number of inpatients- 20/day Number of outpatients- 300/day Separate wing for International Patients: The hospital does not have an exclusive wing for international patients. There is a same set of staff for both the domestic and international patients. Countries of International patients: International patients are from UAE, Nigeria, Oman, and Dubai. Age of International patients: The foreign patients belong to all age groups. Special services provided by medical tourism division: The hospital provides some special services for international patients like online counselling, electronic transfer of medical records, interpreter, special dietary services, and accommodation for companions of the foreign patients. 7. Asian Institute of Gastroenterology Asian Institute of Gastroenterology was established as a new concept of day care unit where major Endoscopic surgical procedures could be done on an outpatient basis without resorting to hospitalization. Since then, the institute has become one of the largest referral centers in Asia for Therapeutic Endoscopy. Patients are referred from not only most cities in India but also surrounding countries like Sri Lanka, Bangladesh, Malaysia, Nepal etc.The hospital has since evolved into a full-fledged 250 beds single specialty hospital with all Gastroenterology subspecialties. Facilities: Number of doctors- 50 Number of nurses- 300 Number of paramedical staff- 30 CESS Monograph - 42 54

Numberof specialization- 1 Number of beds- 250 Number of inpatients- 300/day Number of outpatients- 450-500/day Separate wing for International Patients: There is a separate wing for international patients though the staff is the same for both the domestic and international patients. The staff is also trained to handle international patients. Countries of International patients: The international patients are from Oman, Africa and Sri Lanka. Age of International patients: International patients of all age groups come for treatment. Special services provided by medical tourism division: Online counselling, electronic transfer of medical records, arranging for visa/passport, tie- ups with insurance providers, interpreter, special diet and accommodation for companions of the patients are some of the special services provided by the hospital to international patients. 3.4: Study of International Patients This section is based on the data gathered from the international patients. This section first looks into the background characteristics of international patients who are seeking treatment. An attempt is made to examine the reasons why foreign patients are coming to India for treatment. Thailand, Singapore, Malaysia, India and Philippines are the major destinations in the Asian medical tourism market. Singapore and India specialize in complex procedures with India having a cost advantage and Singapore a technology advantage. The study also attempts to look into their travel and medical expenses. The perceptions and satisfaction levels of international patients regarding the quality of care and rapport with doctors and the staff in the hospital are also explored. Customer satisfaction is a critical issue in the success of any business system, traditional or innovative. Most satisfied customers normally tend to repurchase the products if the performance meets their expectations. 3.4.1: Background Characteristics of International Patients This section examines the background characteristics of international patients. This Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 55 includes the distribution of international patients on the basis of gender, age, marital status, literacy, country and health problem. Table 3.8: Gender Distribution of International Patients Sl.No. Sex Percentage 1. Male 32 59.3% 2. Female 22 40.7% Total 54

The table shows the sex composition of international patients who came for treatment. Out of the 54 international patients interviewed from various hospitals, 32(59.3%) were males and 22(40.7%) females (Table 3. 8).

Studies conducted earlier also show that more male patients come for treatment than females. Indian Institute of Tourism and Travel Management (IITTM) conducted a study across various JCI and NABH accredited hospitals in India. The study shows that among the foreign patients coming to India for treatment 57% were males and 43% females (Prakash et al., 2011). A study of 5 major hospitals in Bangalore also shows that 62% were males and 38% females (Anvekar, 2012). The study on medical tourism in respect of 4 JCI accredited hospitals in Delhi, NCR, also gives the same results. Among the international patients coming to these hospitals for treatment 53% were males and 47% females (Dhodi, Uniyal, & Sharma, 2014). According to a study on 72 foreign patients in Chennai city 58.3% were males and 41.7% females (Sujatha & Subhashini, 2015). Another study conducted among 100 foreign patients from various hospitals in Delhi, NCR, also finds that there were 76% males as against 24% females (Gupta et al, 2015). Reddy conducted a study among 34 patients from hospitals in Bangalore, Hyderabad and Chennai which shows more males (21) than females (13) (Reddy, 2013).

However, as per the study conducted in Delhi among 132 foreign patients, there were more females (59.8%) than males (40.2%) (Sajjad, 2009). Among the international patients coming for treatment to pediatric cardiac care in India, 41% were males and 59% females (Maheshwari, Animasahun, & Njokanma, 2012). CESS Monograph - 42 56

Table 3.9: Distribution of International Patients by Age Group Sl.No. Age Group (in years) Percentage Male Female Total 1. upto-10 6 5 11 54.5% 45.5% 20.4% 2. 11-20 2 3 5 40% 60% 9.3% 3. 21-30 4 0 4 100% 7.4% 4. 31-40 2 4 6 33.3% 66.7% 11.1% 5. 41-50 5 1 6 83.3% 16.7% 11.1% 6. 51-60 9 8 17 52.9% 47.1% 31.5% 7. 61-70 3 1 4 75% 25% 7.4% 8. > 70 1 0 1 100% 1.8% Total 32 22 54 59.3% 40.7% 100% Regarding age distribution of international patients, the maximum numbers are found in the category of 51 to 60 years of age. There were 17 (31.5%) in the age group of 51- 60 years of age, with 52.9% males and 47.1% females. Out of all the international patients interviewed, 11 (20.4%) were below 10 years of age and 9 (16.7%) within 11- 30 years of age. And in the 31-50 years of age category, there were 12 (22.2%) patients out of which 7 (58.3%) were males and 5 (41.7%) females (Table 3. 9). Thus, the international patients were from various age categories with a few patients under less than 30 years. On the basis of data collected using a hospital questionnaire, it was also found that, foreign patients of all age groups came to the hospitals for treatment. The various studies review show that foreign patients were from all age categories. In a study by Dhodi (2014), a majority of the international patients (49%) belonged to the age group of 30-45 years and 26% to the 45-60 years category, whereas in another study by IITTM, a majority (35%) was in the category of 45-60 years, and 31% in 30-45 years age group. In both the studies, few numbers of international patients were under 30 years of age category, 17% in a study by Dhodi and 19% in a study by IITTM. 15% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 57 patients were above 60 years of age in a study conducted by IITTM (Prakash et al, 2011; Dhodi et al, 2014). Another study also shows that only 16.4% were in the 6-12 years age group; 31.5% of patients were in the age group of 24-59 years and 22% in 12-23 years age group (Maheshwari et al, 2012). However, a study by Anvekar shows a different result in that most of the patients belonged to the age group of 20-40 years (72%), 20% in the 40-50 years age group and 8% were above 50 years of age (Anvekar, 2012). According to another study by Sujatha and Subhasini, most of the respondents were in the age category of 18-25 years (Sujatha & Subhashini, 2015). A study by Poonam Gupta also shows that 84% of the patients were in the 20-50 years category, 40% in the category of 31-40 years, 29% in 41-50 and 15% in 21-30 years age category (Gupta et al, 2015). The average age of respondents was 47 years in a study by Reddy, with male average age being 43 years and that of females 54 years (Reddy, 2013). Table 3.10: Distribution of International Patients by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 23 12 35 65.7% 34.3% 64.8% 2. Unmarried 9 9 18 50% 50% 33.3% 3. Divorced 0 1 1 100% 1.9% Total 32 22 54 59.3% 40.7% 100%

Out of the 54 international patients, 35(64.8%) were married and 18(33.3%) unmarried and only 1(1.9%) was divorced. Among the married patients, 23(65.7%) were males and 12(34.3%) females. Only 1 female person was divorced. Thus, more patients are found married than unmarried (Table 3. 10). A review of earlier studies also shows similar results. A study by Dhodi also shows that more (71%) of the medical tourists were married and 29% were single (Dhodi et al, 2014). Similarly, in a study by Sujatha and Subhasini, more (38.9%) were married and 30.6% were unmarried (Sujatha & Subhashini, 2015). A study by Sajjad among 132 foreign patients from various hospitals in Delhi also shows similar results, i.e., 73% married and 25% unmarried (Sajjad, 2009). CESS Monograph - 42 58

Table 3.11:Education-Wise Distribution of International Patients Sl.No. Level of Education Percentage Male Female Total 1. Primary 8 6 14 57.1% 42.9% 25.9% 2. Secondary 3 7 10 30% 70% 18.5% 3. Graduate 10 3 13 76.9% 23.1% 24.1% 4. Post Graduate/MBA 8 1 9 88.9% 11.1% 16.7% 5. Illiterate 3 5 8 37.5% 62.5% 14.8% Total 32 22 54 59.3% 40.7% 100%

The educational status of the respondents shows international patients are distributed across various levels of education with more female illiterates. Out of 8 (14.8%) illiterate patients, 5 (62.5%) were females and 3 (37.5%) males. Among the literates, 14 (25.9%) were primary educated and 13 (24.1%) graduates, whereas 10 (18.5%) were secondary educated and 9 (16.7%) post graduates. Among the primary educated patients, more (57.1%) were males than females (42.9%), whereas in the secondary education category, 70% were females as against 30% males. Among the post graduates, 88.9% were males and 11.1% females (Table 3. 11).

According to a study by Anvekar conducted at 5 major hospitals in Bangalore, most of the medical tourism patients were graduates (67%), while 13% had post graduate degree and 12% with education below 10th (Anvekar, 2012).

Looking at the occupation of the international patients, 16 (29.5%) patients were not working, out of which 87.5% were females and 12.5% males. Of the total patients, 14.7% each were children and students. Among students, 75% were males and 25% females, and among children, males and females were 50% each. Most of the international patients, who were working, were males with only 1 female patient being a Chartered Accountant. Out of the 50 international patients, 32 (59.3%) were not working, children or students, while the rest of the 22 (40.7%) were engaged in some kind of jobs (Table 3.12). Thus, slightly more number of patients were not 'currently' working. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 59

Table 3.12: Occupation-Wise Distribution of International Patients Sl.No. Occupation Percentage Male Female Total 1. Business 9 9 100% 16.7% 2. Private job 3 3 100% 5.5% 3. Construction 1 1 100% 1.9% 4. Chartered Accountant 1 1 100% 1.9% 5. Lawyer 1 1 100% 1.9% 6. Engineer 1 1 100% 1.9% 7. Preacher 1 1 100% 1.9% 8. Priest 1 1 100% 1.9% 9. Military 1 1 100% 1.9% 10. Student 6 2 8 75% 25% 14.7% 11. Teacher 2 1 3 66.7% 33.3% 5.6% 12. Child 4 4 8 50% 50% 14.7% 13. Not working 2 14 16 12.5% 87.5% 29.5% Total 32 22 54 59.3% 40.7% 100% A study by Sajjad also shows that more foreign patients were dependent (51.5%), while 48.5% were self-employed(Sajjad, 2009). However, in a study by Anvekar, only 23% were dependents and the rest were into some kind of jobs (35% respondents were employees, 23% professionals, 19% self-employed) (Anvekar, 2012). According to a study by Sujatha and Subhasini, 38.9% were into the civil servant category of occupation and 25% self-employed (Sujatha & Subhashini, 2015). CESS Monograph - 42 60

3.4.2: Background Characteristics of Family Members of International Patients This section examines the demographic details of the family members of international patients, like the sex, marital status and occupation. Table 3.13:Age-Wise Distribution of Family Members Sl.No. Age Group (in years) Percentage Male Female Total 1. upto-10 15 11 26 57.7% 42.3% 14.4% 2. 11-20 14 16 30 46.7% 53.3% 16.5% 3. 21-30 18 14 32 56.3% 43.7% 17.7% 4. 31-40 13 19 32 40.6% 59.4% 17.7% 5. 41-50 15 10 25 60% 40% 13.8% 6. 51-60 10 13 23 43.5% 56.5% 12.7% 7. 61-70 7 3 10 70% 30% 5.5% 8. >70 3 0 3 100% 1.7% Total 95 86 181 52.5% 47.5% 100%

Among the family members of patients, 17.7% each were in 21-30 and 31-40 years of age categories. In the category of 11-20 years, 30 (16.5%) were there out of which more were females 16 (53.3%) than males 14 (46.7%). There were 3 (1.7%) who were above 70 years of age and all were males. Thus, more of the family members of foreign patients were below 50 years of age (Table 3. 13).

Among the family members of international patients, more were married. Out of 181 members, 58% were married, while 41.4% unmarried. Among the married members, 47.6% were females and 52.4% males, whereas among the unmarried patients, more males (53.3%) were there than females (46.7%) (Table 3.14) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 61

Table 3.14: Distribution of Family Members by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 55 50 105 52.4% 47.6% 58% 2. Unmarried 40 35 75 53.3% 46.7% 41.4% 3. Divorced 1 1 100% 0.6% Total 95 86 181 52.5% 47.5% 100%

Table 3.15: Education-wise Distribution of Family Members Sl.No. Level of Education Percentage Male Female Total 1. Primary 20 18 38 52.6% 47.4% 20.9% 2. Secondary 20 24 44 45.5% 54.5% 24.3% 3. Graduate 22 19 41 53.7% 46.3% 22.7% 4. Post Graduate/MBA 26 17 43 60.5% 39.5% 23.8% 5. MBBS 1 1 2 50% 50% 1.1% 6. Illiterate 6 7 13 46.2% 53.8% 7.2% Total 95 86 181 52.5% 47.5% 100%

Regarding the educational level of the family members of international patients, 20.9% were primary educated, 24.3% secondary educated, 23.8% post graduates and 22.7% graduates, while only 13 (7.2%) were illiterates. Among the illiterate members, 46.2% were males and 53.8% females. Thus, the table reveals more or less the same number of members with various levels of education (Table 3.15). CESS Monograph - 42 62

Table 3.16: Occupation-Wise Distribution of Family Members SL. No Category Occupation Percentage Male Female Total 1 Self Employed Business 21 5 26 80.8% 19.2% 61.9% Charity 3 3 100% 7.1% Doctor 2 1 3 66.7% 33.3% 7.1% Mechanic 1 1 100% 2.4% Priest 1 1 100% 2.4% Lawyer 1 1 100% 2.4% Farmer 1 1 2 50% 50% 4.8% Construction 3 1 4 75% 25% 9.5% Caterer 1 1 100% 2.4% Sub Total 30 12 42 71.4% 28.6% 23.2% 2 Professional /Employee Pharmacist 1 1 100% 2.9% Chartered Accountant 4 3 7 57.1% 42.9% 20.6% Engineer 2 2 100% 5.9% Logistics 1 1 100% 2.9% Media 2 2 100% 5.9% Military 2 2 100% 5.9% Petrol company 1 1 100% 2.9% Private job 5 1 6 83.3% 16.7% 17.7% Royal Guard 1 1 100% 2.9% Teacher 4 6 10 40% 60% 29.5% Works in Hotel 1 1 100% 2.9% Sub Total 22 12 34 64.7% 35.3% 18.8% 3 Dependent Child 7 7 14 50% 50% 13.3% Student 30 22 52 57.7% 42.3% 49.5% Retired officer 1 1 100% 0.9% Not working 5 33 38 13.2% 86.8% 36.3% Sub Total 43 62 105 40.9% 59.1% 58% 4 Grand Total 95 86 181 52.5% 47.5% 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 63

Among the family members, a majority (58%) were dependents, 18.8% professionals/ employees and 23.2% self-employed. The self-employed category included businessmen, philanthropists, doctors, mechanics, priests, lawyers, farmers, construction workers and caterers. The self-employed members were mostly into business (61.9%), of which, 80.8% were males and 19.2% females. The professional/employee category included pharmacists, chartered accountants, engineers, logistics, media, military personnel, working in Petrol Company, private job holders, royal guards, teachers, and those working in hotels. Most of the professionals were teachers (29.5%) followed by chartered accountants (20.6%) and 17.7% doing private jobs. Among the dependent members, which included children, students, retired officers and those not working, 49.5% were students of which 57.7% were males and 42.3% females. Most of the non-working members were females (86.8%) (Table 3. 16). Table 3.17: Country Wise Distribution of International Patients SL.No Region Countries Percentage Male Female Total 1. Africa Nigeria(West Africa) 9 3 12 Cameroon(Central Africa) 1 1 Tanzania(East Africa) 1 1 2 Kenya(East Africa) 4 1 5 Somalia(East Africa) 1 1 Rwanda(East Africa) 2 1 3 Zambia(East Africa) 1 1 Sudan(North Africa) 3 2 5 Total 22 8 30 73.3% 26.7% 55.6% 2. Middle East Countries Oman 1 6 7 Yemen 1 2 3 Kuwait 2 2 Dubai 2 1 3 Total 6 9 15 40% 60% 27.8% 3. South Asia Bangladesh 1 2 3 Total 1 2 3 33.3% 66.7% 5.6% 4. North America Canada 1 1 Total 1 1 100% 1.8% 5. Uzbekistan 2 2 4 50% 50% 7.4% 6. China 1 1 100% 1.8% Total 32 22 54 59.3% 40.7% 100% CESS Monograph - 42 64

The above data reveals that 30 (55.6%) patients came from Africa out of which 22 (73.3%) were males and 8 (26.7%) females, followed by 15 (27.8%) from Middle East countries (40% males and 60% females). There were 4 (7.4%) patients from Uzbekistan and 1 (1.8%) each from Canada and China. Three patients were from Bangladesh as well. Among the patients from Africa, most were from West and East Africa. The sample included patients from only one West African country, that is, Nigeria. Out of the 30 patients from Africa, 12 (40%) were from Nigeria and 12 (40%) from East Africa, 5 (16.7%) from North Africa and 1 (3.3%) from Central Africa. The presence of more number of patients may be due to the fact that Nigeria is one of the top 25 trading partners of India. India is Nigeria's largest export market, accounting for 10.2% of Nigeria's world trade. In 2011, Nigeria's share of total Africa-India trade was 29.4% (Otg, 2012). India is also actively promoting trade with East African countries. A study by India's Exim Bank shows that trade between India and the East African Community (EAC) has risen 13-fold, from USD 490.8 million in 2002 to USD 6.6 billion in 2012 (Kokutse, 2014) (Table 3.17). The data collected through from hospital questionnaire also reveals that the foreign patients in all the hospitals studied, were mostly from Africa and the Middle East. Continental hospital also had patients from Uzbekistan, while CARE hospital from Pakistan and Bangladesh though our sample didn't have patients from Pakistan. A few of the studies reviewed also show similar results. According to a study by Shaikh and Khan, 2006, more patients coming to the study hospitals for treatment were from Arab and African countries (Shaikh and Khan, 2006). A study by IITTM of various JCI and NABH accredited hospitals in India shows that 51% Africans visited India as medical tourists followed by Middle Easterners (35%), South Asians (10%), Westerners (2%) and East Asia also (2%) (Prakash, Nanita Tyagi & Monika., 2011). A study by Poonam Gupta et al also shows that most primarily medical tourists arrived from the Middle East, Africa and South Asia where high quality procedure may not be available at affordable rates(Gupta et al, 2015). However, according to a study by Santosh Kumar in respect of an ophthalmic hospital in NCR Delhi, the most prominent countries for Indian medical tourism are the U.S.A, Britain, UAE, Bangladesh, Pakistan and Mongolia. One-fourth of the total international patients who visited the centre for sight were from the USA/Canada followed by Europe (20%), Britain (12%), Middle East (7%) and Africa (4%). Patients from Britain and Europe prefer India for quick care, while patients from the USA choose India for quality care at low costs. A study by Shanmugan also shows that nearly 50% of the foreign Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 65

Table 3.18: Health Problems of International Patients SL.No WHO Classification Health Percentage of Diseases Problems Male Female Total 1. Infections and HIV 1 1 2 Parasitic Diseases 50% 50% 3.8% 2. Neoplasm Cancer 6 7 13 46.2% 53.8% 24.1% 3. Diseases of Nervous System Neurological 3 2 5 problems 60% 40% 9.2% 4. Diseases of eye and Adnexa Opthalmic 3 2 5 problems 60% 40% 9.2% 5. Diseases of Ear and Mastoid Ear Transplant 1 1 Process 100% 1.8% 6. Diseases of Circulatory System Cardiac 9 3 12 75% 25% 22.2% Pulmonology 1 1 100% 1.8% 7. Diseases of the Digestive System Appendicitis 1 1 100% 1.8% Liver Problem 1 1 100% 1.8% Gastro Intestinal 2 4 6 33.3 66.7% 11.1% Hernia of stomach 1 1 2 50% 50% 3.8% 8. Diseases of the Musculoskeletal Orthopaedic 1 1 2 System and Connective Tissue 50% 50% 3.8% 9. Diseases of Genitourinary System Urology 2 2 100% 3.8% 10. Others Master check up 1 1 100% 1.8% Total 32 22 54 59.3% 40.7% 100% CESS Monograph - 42 66 medical tourists to India were from Maldives and Bangladesh (Kumar, 2009; Shanmugam, 2013). Similarly, a study conducted by Reddy among 34 international patients reveals that approximately two thirds of the respondents were from the USA (73%).There were 6% of patients from Canada and UK and 3% each from Sweden, Austria, Holland, Switzerland and Nigeria. Thus, a majority of the foreign patients come from the Developed countries. Most of the patients were nonresident Indians (NRI) from the USA, Indians who live and work in the USA on a permanent basis, but have families in India (Reddy, 2013). Another study by Jasmin Padiya and Snehal Goradara also observes that NRI Americans are more attracted towards India and that the number of Gujarati people settled abroad are more in members who come to India for medical treatment. The study further shows that 45% were from the USA, 17% from UK, 20% from Africa, 8% from Australia and 10% from other countries like New Zealand, Canada, Mauritius, Fiji Islands and Middle East (Padiya & Goradara, 2014). But the study by Sajjad shows that foreign patients from all parts of the globe are coming to India for treatment i.e., 21% were from Iran, 12% from Iraq, 9% each from Pakistan, Nigeria and Afghanistan, 6% each from Bangladesh and Sri Lanka, 4% from Ethiopia, 3% each from UAE, UK, Japan, Nepal, Rwanda and Singapore, 2% each from Bhutan, Uzbekistan and Yemen and 8% each from Kazakhstan, Liberia, Uganda, Sudan, Poland and Saudi Arabia (Sajjad, 2009). The health problems of international patients have been categorized into the following groups based on the International Classification of Diseases (ICD)-10, WHO. The same classification is followed for Chennai and Mumbai chapters. Infections and parasitic diseases ● Human immunodeficiency virus disease (HIV) ● Ear Nose Throat (E.N.T) Neoplasms ● Cancer Diseases of nervous system ● Neurological diseases Diseases of eye and adnexa ● Opthalmic problems Diseases of ear and mastoid process ● Ear transplant Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 67

Diseases of circulatory system ● Cardiac ● Pulmology Diseases of the digestive system ● Appendicitis ● Liver problem ● Gastro- intestinal diseases ● Hernia Diseases of the musculoskeletal system and connective tissues ● Orthopaedic ● Back pain Diseases of genitourinary system ● Urology ● Gynaecology ● Kidney problem ● Endometric cyst Endocrine, nutritional and metabolic diseases ● Sugar problem Master checkup On examining the health problem details of international patients coming to India for treatment, it was found that 13 (24.1%) had come for cancer treatment, followed by cardiac treatment (22.2%). There were 6 (11.1%) patients with gastro intestinal problems and 5 (9.2%) each had neurological and ophthalmic problems. Among the cancer patients, 53.8% were females and 46.2% males. Similarly, among the patients with gastro-intestinal problems, more were females (66.7%) than males (33.3%). However, among the patients with cardiac problems more (75%) were males than females (25%). The international patients come for treatment of many different kinds of health problems rather than any single type of procedure. The dominance of patients coming for cancer and cardiac treatment may be due to the fact that the patients were from the 2 specialized hospitals of cancer and heart (Basavatarakam Indo American Cancer Hospital and Research Institute and Care Hospital) (Table 3.18). CESS Monograph - 42 68

The study conducted in respect of 4 JCI accredited hospitals in Delhi NCR, shows that more patients had come for cardiac treatment. Among the medical tourists, 13% came for gastroenterology, 35% for cardiology, 19% for orthopedics, 9% for cancer and 7% for neuro-surgery (Dhodi et al, 2014). Similarly, according to a study carried out by Santosh Kumar, most foreign patients come to India for cardiac procedures as cardiac procedure is cheapest in India. Bypass surgery is cheapest in India (9300 dollars), while in USA it is 100,000 dollars, 16,500 dollars in Singapore and 11,000 dollars in Thailand (Kumar, 2009). A study conducted across various JCI and NABH accredited hospitals in India also shows that cardiac treatment (30%) is the most popular procedure in Indian medical tourism, followed by orthopaedic (15%), nephrology (12%), neurosurgery (11%) and others (22%) (Prakash et al, 2011). Other studies reviewed reveal that foreign patients take multiple system treatment for various diseases. Popular medical treatments sought by patients include cardiac, orthopaedic, oncology, eye surgery, neurology and tumour. According to a study by Sajjad, among 132 foreign patients in Delhi, 59.8% had come for orthopaedic treatment, 28% for cardiac treatment, 4.5% for cosmetic surgery and 7.6 for various other kinds of treatments (Sajjad, 2009; Padiya & Goradara, 2014; Gupta et al, 2015). However, according to Reddy, the four most common medical treatments included hip resurfacing (15), repetitive strain injuries, preventive care like diabetes, obesity and depression and various types of dental treatments (Reddy, 2013). 3.4.3: Reasons for Coming to India This segment examines the reasons for which international patients choose to come to India for treatment. Patients from the developed countries may seek medical treatment in another country mainly with a view to avoiding high costs and long waiting periods in their countries. Patients with no insurance or underinsured may also seek treatment in other developing countries, while people from under developed countries may opt for medical tourism due to the non-availability of specialized doctors and treatments in their countries. A few also may look to combine tourism with treatment. For an overwhelming 90.7% of the international patients coming to India (Hyderabad) for treatment doctors' specialization is the main reason for choosing India. In view of relatively low costs of treatment, 31.5% of the patients chose India. The number of patients, who came to India (Hyderabad) because treatment was not available in their country, was 18.5%. And only 5.6% had come to avoid long waiting time for treatment in their country (Table 3.19). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 69

Table 3.19: Reasons for Choosing India for Treatment Sl.No. Reasons Percentage 1. Low cost 17 31.5% 2. Specialized doctors 49 90.7% 3. Long waiting time in their country 3 5.6% 4. Combining vacation with treatment 1 1.9% 5. Treatment not available in their country 10 18.5% 6. Had accompanied uncle for his treatment but 1 developed some cardiac problem 1.9% 7. Government recommendation 1 1.9% Total 82 151.8% Note: Due to multiple answers, percentage may exceed 100 Earlier studies reviewed show that the main reason for patients coming to India for treatment is the prevalence of low costs. A study conducted by Anvekar in respect of 5 major hospitals in Bangalore shows that 48% came due to low costs of medical treatment, 24% visited due to an insurance budget limit, and 4% came as it is their home country (Anvekar, 2012). A study by Poonam Gupta reveals that 91% came to India because of low costs of medical procedures, 87% found the cost of travel and stay low, and 64% for its quality of medical procedures. Less waiting time for treatment was another significant factor for choosing India in the case of 66% patients (Gupta et al, 2015). As per other studies, the expertise of doctors was the most important factor in the choice of medical treatment (Reddy, 2013; Padiya & Goradara, 2014). According to another study, the relatively low cost of procedures was the major reason for one-third of the patients for choosing India as a medical tourism destination. Moreover, the lack of quality care services in their home country brought patients to India from Indian sub continent (Kumar, 2009). The study shows that 68.5% of the international patients had come to know about the hospital from friends and relatives who had already been treated in India in this hospital CESS Monograph - 42 70 and in the case of 38.9% of the patients, the doctors at their place had suggested the doctor and the hospital, while only 9.3 percent had come to know about it from the website (Table 3. 20). Table 3.20: Who Suggested this Place and Hospital Sl.No. Who suggested the place Percentage 1. Friends/Relatives 37 68.5% 2. Doctors at their place 21 38.9% 3. Website 5 9.3% 4. Staff of the hospital 1 1.9% Total 64 118.5% Note: Due to multiple answers, percentage may exceed 100

However, the World Health Tourism Congress, 2007 report says that a large number of patients use the internet to get information about the healthcare providers. Among the patients in an Eye care centre in Delhi, NCR, 20% had reported advertisement as a major source of information given by corporate hospitals in the local media, newspapers and magazines (Kumar, 2009). Similar to this study, an earlier study conducted across various JCI and NABH accredited hospitals in India reveals that, around 50% of the respondents had come to know about the service providers from friends and relatives, while 29% had been referred by doctors treating them at home. The services of a medical tour operator were used by 7% (Prakash et al, 2011). The study by Poonam Gupta also shows that more patients had been referred by their family and friends (33%) followed by internet (26%) and doctors and hospitals in home country (25%). Personal recommendation was also the reason behind choosing India in a study by Reddy. Another study by Padiya and Goradara also concludes that a positive word-of-mouth plays a vital role in attracting foreign patients. The study shows that 75% patients had got information from their relatives or friends, 17% from websites and very few from magazines, newspapers and television - 3%, 4% and 2% respectively (Reddy, 2013; Padiya & Goradara, 2014; Gupta et al, 2015). However, in a study in Pediatric care centre in India, a majority of the international patients had been referred by their local Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 71 doctors (71.2%) followed by 13.7% each by non-governmental organizations and friends, while Internet had been least used (1.4%) (Maheshwari et al, 2012). Table 3.21: Medium of Contact with the Hospital S.No Medium of contact Percentage 1. Online 41 75.9% 2. Over the phone 28 51.9% 3. Personally came to the hospital 5 9.3% 4. Through friends who stay here 6 11.1% 5. Government arranged everything, we had to just come here 1 1.9% 6. Doctor 2 3.7% 7. Since I was here in the hospital with another patient 1 1.9% Total 84 155.5% Note: Due to multiple answers, the aggregate percentage may exceed 100 When asked how they contacted the hospital, 75.9% of the respondents responded that they had contacted the hospital online, 51.9% had contacted over the phone and 11.1% had friends staying here who first approached the hospital with the reports of the patient. For 3.7% of the patients, the doctor at their place had contacted the hospital. Thus, the medium of contact for most of the foreign patients were phone and online (Table 3. 21). Apart from the above contact sources, the hospital personnel revealed that the hospitals also provided many special services to foreign patients like on-line counselling and electronic transfer of medical reports. Basavatarakam Indo American Cancer Hospital and Research Institute (BIACH&RI) has registered itself with a service provider called Placidway. Whoever visits the site is informed to the hospital by the service provider. The staff from the hospital approaches the patient over phone, and thereafter the patient sends his reports online. CESS Monograph - 42 72

Table 3.22: Facilities that Attracted the International Patients to This Hospital Sl.No. Facilities Percentage 1. Doctors' Specialization 54 100% 2. Treatment charges 10 18.5% 3. Infrastructure 16 29.6% 4. Accommodation 3 5.6% 5. Hospitality 13 24.1% Total 96 177.8% Note: Due to multiple answers, the aggregate percentage may exceed 100 All the respondents chose the hospital because of the doctors' specialization (100%). Along with doctors' specialization, for 29.6% of the respondents, the infrastructure of the hospital was also a reason for choosing the hospital, followed by 24.1% who were attracted by the hospitality of the hospital and 18.5% who were attracted by the relatively low treatment charges. For only 5.6 percent of the respondents, accommodation was one of the reasons for their choosing the hospital (Table 3.22). All the hospitals visited have accommodation facility for attendant of international patients. However, only a very few international patients, during this study, cited accommodation as the factor that had attracted them to the hospital. All the patients came to the hospital because of the doctors' specialization. An earlier study by Poonam Gupta also shows that the profile of doctors is the most important factor (43%) in the selection of the hospital and the quality of medical procedures (36%). Brand name of the hospital and the advice of family members and friends were also the factors behind the choice of the hospital (Gupta et al, 2015). However, a study by Sajjad shows different findings in that a majority of the patients (73.5%) were attracted by the quality of services provided at the hospital; for 11.4% of the patients, ease and affordability of travel was the reason for them to choose the hospital; a long waiting time in their country was the reason to choose this hospital for 6.1% of the patients. And in respect of 9.1%, of the patients, a high cost in their country was the reason (Sajjad, 2009). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 73

Table 3.23: Difficulties Faced in Their Country Sl.No. Difficulties in their country Percentage 1. Disease not being diagnosed properly 7 13% 2. Non-availability of specialists for the problem 46 85.2% 3. Delay in getting appointments 5 9.3% 4. Since coming to India for cousins' treatment 2 3.7% 5. NRI 1 1.9% 6. Treatment for adopted child 1 1.9% Total 62 114.8%

Note: Due to multiple answers, the aggregate percentage may exceed 100 The above table shows that, 85.2% of the respondents opted for medical tourism due to the non-availability of specialists for problems faced in their country. According to 13% of the patients, the failure to diagnose the disease properly in their country was the reason for their coming here and for 9.3% of the patients, an undue delay in getting appointments was the reason for them to choose another country for treatment (Table 3.23). Opting for medical tourism by people of different countries may be due to various reasons. In some countries, for people who don't have health insurance may opt to go to another country where they can get the same treatment at cheaper rates. From some other country, patients may choose another country for treatment to avoid lengthy waiting period in their home country. In some other cases, to visit another country may be a reason for some international patients to opt for out-of-the country medical tourism (Rutherford, 2009). 3.4.4: Visa This section deals with patients' experience while applying for visa. A special visa called the medical visa was introduced in India in 2005 with a view to facilitating the international patients visiting India for treatment. The visa is valid for one year and CESS Monograph - 42 74 requires the patients to register with the Foreigner Regional Registration Office within two weeks of their arrival. However, this was taxing and sometimes insulting for the patients having serious health problems (The ET, August 2013). In the SAARC summit (2014), Prime Minister Narendra Modi made an announcement that immediate visas would be provided to patients from South Asian Association for Regional Cooperation (SAARC) countries. This announcement is intended to give a huge boost to medical tourism in India as many patients from the SAARC countries come to India for treatment. Medical excellence has always attracted patients from different countries to India but cumbersome visa rules have always diverted patients to other countries like Malaysia, Thailand and Singapore (The ET, 28 Nov, 2014). Table 3.24: Any Difficulties faced While Applying for Visa Sl.No. Any difficulties Percentage 1. Yes 8 14.8% 2. No 41 75.9% 3. No embassy in our place, the counselor has to 1 go to Nigeria, so charges double the money 1.8% 4. If the visa is urgent, they charge double the money 1 1.8% 5. Lifelong visa/Overseas Citizenship of India(OCI) 2 3.7% 6. Indian citizen 1 1.8% Total 54 100% When asked whether they faced any difficulties while applying for visa, 75.9% out of 54 patients in Hyderabad said that they didn't have any problems, while 14.8% had some kind of problem. Two (3.7%) patients had lifelong visa/OCI and 1(1.8%) had Indian citizenship. One (1.8%) patient was of the opinion that if visa was needed urgently, they would charge double the money. The patient from Cameroon (1.8%) was of the opinion that since there is no embassy in their country, the counselor had to go to Nigeria for visa because of which they charged double the money. However, almost all the patients were of the opinion that getting visa to India was a lengthy process and could be frustrating for patients, particularly those with serious health problems (Table 3. 24). As evident from the data collected using a hospital questionnaire, all the study hospitals reported that they had helped the foreign patients in arranging for visa and passports. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 75

As per a study by Goyal, in Delhi NCR, 63% of the respondents found the visa process in India cumbersome requiring patients to submit/produce many documents to support their candidature for visiting India (Goyal, 2014). Table 3.25: Whether the Staff at the Indian Embassy Friendly and Helpful Sl.No. Whether the staff at Embassy friendly Percentage 1. Yes 41 75.9% 2. No 7 13.0% 3. Didn't deal with the embassy 6 11.1% Total 54 100% Most of the international patients (75.9%) who had applied for visa found the staff at the Indian Embassy friendly and helpful, while 12.9% did not, and six patients didn't have to deal with the embassy as they were either Indian citizens or having Lifelong visa/Overseas citizenship of India or opting for visa on arrival (Table 3.25). Table 3.26: Distribution of Patients by Type of Visa Sl.No Type of visa Percentage 1. Medical visa 40 (74.1%) 2. Tourist visa 4 (7.4%) 3. Student visa 1 (1.8%) 4. Volunteer visa 1 (1.8%) 5. Medical & Tourist Visa 5 (9.2%) 6. OCI 2 (3.7%) 7. Indian citizen 1 (1.8%) Total 54 (100%) CESS Monograph - 42 76

Out of the total international patients interviewed, 40 (74.1%) had medical visas. The number of patients having both the medical and tourist visas was 5 (9.2%); 2 (3.7%) had OCI (Overseas Citizenship of India); 4 (7.4%) had only tourist visas; 1 (1.8%) had student visa; 1 (1.8%) had volunteer visa and 1 (1.8%) had Indian citizenship (Table 3. 26). A study by IITTM in respect of various JCI and NABH accredited hospitals in India shows that many medical tourists visited India on tourist visas as medical visas were costlier and cumbersome (Prakash, Nanita Tyagi & Monika., 2011). Table 3.27: How Many Days did you Get the Visa For Sl.No. Number of days Percentage 1. 1 month 7 13.0% 2. 2 months 13 24.1% 3. 3months 10 18.5% 4. 6 months 19 35.2% 5. 2 years 1 1.8% 6. 3 years 1 1.8% 7. Indian Citizen/lifelong citizen/OCI 3 5.6% Total 54 100% Out of the 54 international patients, 19 (35.2%) had got visa for 6 months, 13 (24.1%) for 2 months, and 10 (18.5%) for 3 months. Only one (1.8%) each had got visa for 2 and 3 years and 5.6% patients were either Indian citizens or Lifelong citizens or OCI (Table 3.27). 3.4.5: Medical and Travel Expenses This segment examines the medical and travel expenses of international patients, and also whether they had planned to do some tourism while being in India. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 77

3.4.5a. Insurance One of the main reasons behind people opting for medical tourism is that they are not covered or partially covered by insurance. However, many of the insurance and self- insured companies offer incentives to their customers to opt for medical tourism and treatment in a particular country and hospital. Table 3.28: Do They Have Health Insurance Sl.No. Whether having health insurance Percentage 1. Yes 4 7.4% 2. No 48 88.9% 3. Sponsored by government 2 3.7% Total 54 100% Out of the 54 international patients interviewed in Hyderabad, 48(88.9%) patients did not have any health insurance, while 4(7.4%) had insurance and 2(3.7%) patients were sponsored by the government of their country (Table 3. 28). Although the Continental hospital and Asian Institute of gastroenterology have tie-ups with insurance providers, our results show that very few had health insurance coverage. The studies reviewed also show that most of the international patients coming to India for treatment were self-supported. According to a study with respect to a pediatric care centre in India, 53% of the patients from Nigeria were sponsored by self, 29% by non- governmental organizations, 12% by parent employer and 6% by the government (Maheshwari et al, 2012). According to a study by IITM in respect of various JCI and NABH accredited hospitals in India, 81% of the respondents had supported their own medical treatment, while 16% were supported by their respective governments and only 2% had insurance cover (Prakash et al, 2011). The study by Sajjad also shows that only 18.2% of the medical tourists had availed themselves of insurance facilities for their treatment in India. A study by Poonam Gupta also reveals a very few patients (17%) had come with insurance and an overwhelming 78% had self-financed their treatment. The Government and charitable agencies sponsored patients accounted for only 2% and 3% respectively. But as per a study by Reddy, a little more than half had health insurance and the rest were without any health insurance (Sajjad, 2009; Reddy, 2013; Gupta et al, 2015). CESS Monograph - 42 78

Table 3.29: Would They Have Been Able to Come to India without Health Insurance Sl.No. Whether able to come without health insurance Percentage 1. Yes 3 75% 2. No 1 25% Total 4 100% Out of the 4 patients with health insurance, 3 (75%) patients said they would have been able to come to India even without health insurance, while only 1(25%) patient could not have been able to come without a proper health insurance (Table 3.29). The study reviewed also show that almost all the patients would have been able to come to India without their health insurance covering their expenses (Reddy, 2013).

Table 3.30: Did Health Insurance give them Any Additional Incentive to Come to India? Sl.No. Additional incentive by health insurance Percentage 1. Yes 0 2. No 4 100% Total 4 100% All the 4 patients who had come with health insurance said that their health insurance didn't give any additional incentive to come to India (Table 3.30). 3.4.5b: Expenditure Complicated surgeries and treatment are made possible in the developing countries like India at almost 1/10th of the costs prevailing in the developed countries. Indian medical tourism is being promoted as First World Treatment at Third World costs. These lower costs are especially important for patients not covered by health insurance and for who a procedure may be financially burdensome in the home country. Out of the 54 respondents in Hyderabad, 32 patients gave information about the cost of their treatment and stay in the hospital. Out of the 22 patients, who didn't give any information about the cost, 12 patients had no idea about the cost as their treatment was still continuing. In the case of 6 patients, the hospital authorities didn't allow the patients to be enquired about the cost part, while 3 patients didn't want to tell. On an average, the 32 patients had spent $ 5931.99, ranging from a minimum of $ 29.91 and a maximum of $ 23000 (Table 3. 31). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 79

Table 3.31: Cost of Treatment and Stay Place Reasons Number Mean Std Deviation Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) Sponsored by government 1 No idea till now 12 Was not allowed to ask by the hospital authority 6 Didn't tell 3 Hyderabad Total 22 Number of patients giving amount 32 5931.99 5901.10 29.91 23000.00 3771.25 Total 54 The study by Reddy among 34 patients from different hospitals in Bangalore, Hyderabad and Chennai also shows that, the amount spent by international patients for their treatment and stay was much less with a minimum cost of $ 300 and a maximum of $ 16000. The average cost for treatment and stay was $ 6071 (Reddy, 2013). Table 3.32: The Cost of Entire Trip to India Place Reasons Number Mean Std Deviation Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) The attendant had no idea 10 Everything arranged by the government 3 Was not allowed to ask by the hospital authority 5 Didn't tell 2 Hyderabad Student in Hyderabad 1 Total 21 Number of patients giving amount 33 1850. 28 2178.95 101.90 9702.00 983.18 Total 54 CESS Monograph - 42 80

Out of the 54 patients, 33 gave some information about the cost of their travel and trip to India. There were 21 patients who didn't give any information, out of which 5 patients were not allowed by the hospital authority to speak about it, while in the case of 10 patients, the attendant had no idea nor were the patients in a position to speak. On an average, the 33 patients giving information had spent $1850.27 for their travel to India, ranging from a minimum of 101.90 $ and a maximum of $ 9702.00 (Table 3. 32). The earlier study among international patients in a pediatric care centre in India show that more than 70% of the respondents had spent more than 1000 dollars each on transportation (Maheshwari et al, 2012). 3.4.5c: Tourism Medical tourism includes people travelling to another country for treatment as well as tourism. Thus, it includes two types of services - healthcare and tourism. Patients may want to travel to countries with exotic locations where they can spend their vacation along with treatment. Table 3.33: Planning to do Any Tourism While being in India Sl.No. Any plan of tourism Percentage 1. Yes 21 38.9% 2. No 26 48.1% 3. Would love to, but have to go back 5 9.3% 4. Already visited India earlier and seen many places 2 3.7% Total 54 100%

On enquiring whether the patients wanted to visit some places post their treatment, 38.9% replied in affirmation, while 48.1% said "no". Only 9.3% of the patients said that they would have loved to visit some places, but they were to go back as they had work to look after, while 3.7% of the patients had earlier visited India and seen many places (Table 3.33). The study hospitals namely, Basavatarakam Indo American Cancer Hospital, CARE Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 81 and Continental hospital, offer special services in terms of arranging for medical tourism facilitators for international patients. The earlier studies also show the same results. The study by Sajjad reveals that 49.2% did not want to do any tourism, while only 8.3% wanted to visit a few places post treatment, Padiya and Goradara in their study found that a majority (60%) of the medical tourists had come to India with the purpose of treatment with tourism, 34% for treatment with attending some social gatherings and only 6% for treatment along with shopping. According to a study by Reddy, 20 out of 34 patients might have travelled locally in view of their already being in the city, however, they were not in a condition to do any travelling, given their recovery period. Fourteen patients had planned to travel outside the city as well, while 24 had come primarily for treatment and10 patients had planned to do some travelling while being in India. However, for a majority of the patients travelling was not an important aspect during their stay in India (Padiya & Goradara, 2014; Sajjad, 2009; Reddy, 2013). Table 3.34: If yes, Places you would Like to Visit Sl.No. Places Number 1. Bangalore 1 2. Charminar 1 3. Goa 1 4. Golconda, Tajmahal 1 5. Haven't Decided 3 6. Places in Hyderabad 11 7. Places in Hyderabad, and if time permits, other places in India 1 8. Places in Hyderabad and Mumbai 1 9. Mumbai 1 Total 21 Most of the patients coming to Hyderabad for treatment wanted to visit places in Hyderabad, while a few (3) patients had not decided on the place and 4 wanted to visit other places in India as well (Table 3.34). 3.4.6: Availability of Translators/Interpreters This segment deals with whether international patients face any problem with various languages in India and whether hospitals provide interpreters. In fact, the growth in medical tourism has led to a growth in interpreters who assist foreign patients in their communication with doctors and healthcare attendants. Mostly affluent patients from CESS Monograph - 42 82

Arabic countries face the language problem in India because of which there is a great demand for Arabic interpreters. Table 3.35: Problems with Language Sl.No. Problems with language Percentage 1. Yes 12 22.2% 2. No 41 75.9% 3. Staff here don't understand English 1 1.9% Total 54 100% Most of the international patients didn't face any language problem as they knew English. Out of 54 patients interviewed, 75.9% reported that they did not face any problem with respect to language, while 22.2% patients faced some kind of problems. One patient was of the opinion that the staff didn't understand English (Table 3. 35). Table 3.36: Whether the Hospital Provides Interpreters for those with Language Problem Sl.No. Availability of interpreters Percentage 1. Yes 11 84.6% 2. No 2 15.4% Total 13 100% Out of the 13 patients faced with the language problem, 11 said that the hospital had provided interpreter, while 2 said there was no interpreter (Table 3. 36). Among all the important services provided by hospitals to the international patients, the most important is the provision of interpreters. LV Prasad Eye Institute didn't have any other special services apart from providing interpreters for foreign patients. The study by Sajjad among 132 foreign patients in Delhi reveals that for nearly 84.8% of the patients, interpreters were not always available, and that interpreters were available only for 15.2% of the respondents (Sajjad, 2009). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 83

3.4.7: Quality of Care This segment deals with the perceptions of international patients regarding the quality of care provided at the hospital and the satisfaction level of patients. Patient satisfaction with the services provided is an essential indicator of the quality of healthcare delivery. A study conducted by Indu Grewal et al among 49 patients from 6 tertiary care hospitals in New Delhi shows that, most of the patients were satisfied with doctors, nursing care, rooms, toilet, cleanliness and reception services, excepting the taste of food (Grewal et al, 2012). Table 3.37: Problems, if any, during Admission at the Hospital Sl.No. Problems during admission Percentage 1. Yes 2 3.7% 2. No 51 94.4% 3. Waiting for a long time 1 1.9% Total 54 100% Out of the 54 international patients interviewed, 51(94.4%) patients didn't have any problem during admission at the hospital, while only 2(3.7%) patients faced some problems during admission and 1 patient had to wait for a long time (Table 3. 37). Foreign patients are usually specially treated by the hospital staff as evident from the data collected from hospitals. The foreign tourist wing at CARE hospital has 15 beds, 12 workers and 15 staff, while Basavatarakam Indo American Cancer Hospital and Cancer Institute has 38 beds in its international wing. Table 3.38: Whether the Staff was Courteous, Polite, Friendly and Helpful Sl.No. Whether friendly staff Percentage 1. Yes 53 98.1% 2. No 1 1.9% Total 54 100% According to 53 (98.1%) international patients interviewed, the hospital staff was CESS Monograph - 42 84 courteous, polite, friendly and helpful, while only 1(1.9%) patient found the hospital staff not courteous, polite, friendly and helpful (Table 3. 38). Among all the hospitals visited, Basavatarakam Indo American Cancer Hospital and Cancer Institute, CARE, Continental and Krishna Institute of Medical Sciences have an exclusive wing for international patients with a specially trained staff. The other hospitals visited - L V Prasad Eye Institute, Asian Institute of Gastro-enterology and Kamineni hospital - do not have a special wing for medical tourists, though the staff is specially trained to deal with international patients. Table 3.39:Procedures Suggested by the doctors Sl.No Procedures Percentage 1. X-ray 34 62.9% 2. Some specific diagnostic techniques 4 7.4% 3. Chemotherapy 3 5.6% 4. Routine Blood Test 38 70.3% 5. MRI 2 3.7% 6. C.T.Scan 10 18.5% 7. PET.Scan 5 9.3% 8. ECG/Echo 11 20.4% 9. Ultrasound 2 3.7% 10. Mamography 1 1.9% 11. Endoscopy 2 3.7% Total 112 207.4% Note: Due to multiple answers, the aggregate percentage may exceed 100. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 85

According to a research paper in the International Research Journal of Business and Management, the medical tourists are satisfied with the service providers in Delhi NCR. 20% of the patients considered the overall experience as excellent, 60% as very good, 15% as good and only 5% as poor (Dhodi et al, 2014). The study by Sajjad also suggests that foreign patients were satisfied by the overall experience with the hospital in that out of a total of 132 patients in various hospitals in Delhi, 88.6% of the patients had found the overall experience good, 2.3% excellent and 9.1% satisfactory. In a study by Padiya and Goradara, 48% out of 100 foreign patients were satisfied by the overall facilities provided in the hospital, 30% were highly satisfied, 16% were neutral and only 6% were dissatisfied with the facilities in the hospital (Padiya & Goradara, 2014; Sajjad, 2009).

Most of the patients (70.3%) were advised to go for a routine blood test along with some specific diagnostic procedures (7.4%); ECG/Echo for heart patients (20.4%); X- ray for orthopedic patients (62.9%); and C.T. Scan for neurological patients (18.5%) (Table 3. 39). All these diagnostic facilities are available within the respective hospitals.

Table 3.40: Stages of Treatment Sl.No. Stages Percentage 1. Treatment is over 17 31.5% 2. Still continuing with treatment 34 62.9% 3. Regular checkups after treatment 2 3.7% 4. Waiting for operation 1 1.9% Total 54 100%

Out of the 54 international patients interviewed, 34(62.9%) were still continuing with the treatment while the treatment was over for 31.5% patients and 1(1.9%) patient was waiting for the operation. Two patients had come for regular checkups after treatment (Table 3. 40). CESS Monograph - 42 86

Table 3.41: Whether Satisfied With The surgical Procedure Sl.No. Satisfied with surgical procedure Percentage 1. Yes 28 51.9% 2. No 3 5.5% 3. No operation needed 11 20.4% 4. Not yet operated 11 20.4% 5. operation going on 1 1.8% Total 54 100% Out of 54 international patients interviewed, more than half the patients (51.9%) were satisfied with the surgical procedure they had undergone, while 3 (5.5%) patients were not satisfied. For 11 (20.4%) patients, no operation was needed and 11 (20.4%) patients were yet to be operated and for 1 patient, the operation was going on. Thus, the patients who had undergone operations were satisfied by the surgical procedure, excepting 3 patients who were not satisfied (Table 3. 41). Table 3.42: Whether Satisfied With the Doctor Sl.No. Satisfied with doctor Percentage 1. Yes 51 94.4% 2. No 2 3.7% 3. After operation, doctor hasn't come for checkup 1 1.9% Total 54 100% Out of the 54 international patients, 94.4% patients were satisfied with the doctor while 3.7% were not satisfied. 1 patient said that the doctor had not come for checkups even after a few days of the operation (Table 3. 42). The findings are in compliance with an earlier study which shows that 55% of international patients from 5 major hospitals in Bangalore were satisfied with the Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 87 physician's proficiency while for 45%, it was excellent (Anvekar, 2012). A study conducted among 100 patients from Ahmedabad also reveals that, 56% of the foreign patients were satisfied with the treatment they had received, 25% were highly satisfied, 11% were neutral, 7% were dissatisfied and 1% were highly dissatisfied (Padiya & Goradara, 2014). Table 3.43: Whether Satisfied With Care Takers at the Hospital Sl.No. Whether Satisfied with care takers Percentage 1. Yes 54 100% 2. No 0 Total 54 100% All the 54 patients were satisfied with care-takers of the hospital (Table 3. 43). In support of this study findings, an earlier study in respect of a super specialty Eye Hospital in Delhi NCR, shows that all the patients interviewed were satisfied with the overall care provided at the Centre. Moreover, they were also willing to refer the hospital to their friends and relatives. The satisfaction level could be attributed to a short stay at the hospital as also cosmetic surgery with no complications (Kumar, 2009). The experience was good for 81.1% of the patients, satisfactory for 15.9% and excellent for 3%,according to a study by Sajjad among 132 patients from hospitals in Delhi (Sajjad, 2009). Table 3.44: Whether the Hospital providing Medicines as Prescribed by Doctors Sl.No. Hospital providing medicine Percentage 1. Yes 52 96.4% 2. No 1 1.8% 3. No medicine has been prescribed 1 1.8% Total 54 100% In almost all the cases (96.4%), medicines prescribed by doctors were provided by the hospital. Only one patient said that the hospital hadn't provided any medicine as prescribed by doctors, while in the case of one patient, no medicine had been prescribed by doctors (Table 3. 44). CESS Monograph - 42 88

Table 3.45: If not, where are they Available Sl.No. Availability of medicine Percentage 1. Available in the hospital only 1 100% 2. In all places in city 0 3. Only in few places 0 4. Any other (specify) 0 Total 1 100%

The only international patient reporting that the hospital had not provided the medicine prescribed by the doctor also said that the medicine was available in the hospital only (Table 3. 45).

Table 3.46: Whether Information Regarding Recovery Given to Family by Doctor / Nurse Sl.No. Information regarding recovery Percentage 1. Yes 47 87.0% 2. No 5 9.3% 3. Will tell after surgery 2 3.7% Total 54 100%

When asked whether information regarding recovery had been given to the family members by the doctor/nurse, 47 (87%) patients answered in affirmation, while the families of 5 (9.3%) patients were not given any information and 2 patients were of the opinion that they would be given information only after the surgery (Table 3. 46).

When asked whether the nurse/doctor explained the purpose of medicine to be taken at home, 51.9% of the patients said "not yet", as the treatment was going on, 37% of the patients said "no", while 9.2% of the patients had been explained about the medicine to be taken at home. And in the case of 1 (1.9%) patient, no medicine was to be taken at home (Table 3. 47). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 89

Table 3.47: Whether the Nurse/Doctor Explained the Purpose of Medicine to be Taken at Home Sl.No. Purpose of medicine explained Percentage 1. Yes 5 9.2% 2. No 20 37.0% 3. Not yet 28 51.9% 4. No medicines to be taken at home 1 1.9% Total 54 100%

Table 3.48: Whether Satisfied With the Hygiene and Cleanliness at the Hospital Sl.No. Satisfied with hygiene Percentage 1. Yes 47 87.0% 2. No 1 1.9% 3. Compared to other places good 3 5.5% 4. Not sure 1 1.9% 5. Yes, but there is room for improvement 2 3.7% Total 54 100% Out of the 54 international patients, 87% were satisfied with the hygiene and cleanliness at the hospital, while one patient was not satisfied. Three patients felt that, as compared to other places, it was good and according to two patients, there was room for further improvement, while one patient was not sure. Thus, most of the patients were satisfied with the hygiene and cleanliness at the hospital, but there was still scope for improvement (Table 3. 48). As evident from the observation tool, hygiene and cleanliness are maintained in all the hospitals we visited. The cleaning staff was continuously cleaning within the hospital premises. However, in Continental hospital, according to the attendant of the foreign CESS Monograph - 42 90 patient, the hospital was clean, but was not sure of the hygiene part. The security people went inside the ICU with their shoes on, while the attendants of the patients were asked to take off their shoes. According to an earlier study, 76% of the patients were satisfied with sanitation at the hospital, while 18% were not satisfied and for 6% it was excellent (Anvekar, 2012).

Table 3.49: Whether the Hospital Provided Accommodation for Attendant/s Sl.No. Accommodation for attendant/s Percentage 1. Yes 51 94.4% 2. Do not have an accompanying person 3 5.6% Total 54 100%

For 94.4% of the international patients in Hyderabad, the hospital provided accommodation for the attendant/s of the patient. And the rest 3 (5.6%) of the patients didn't have any attendant accompanying them (Table 3. 49).

Similar findings are also revealed by a study conducted among 132 foreign patients in Delhi. In the case of 81.1% of foreign patients, accommodation was arranged by the hospital and the travel agent looked after accommodation in respect of 14.4% and for only 4.5% patients, it was arranged by their friends and relatives. A study with respect to 5 major hospitals in Bangalore shows that 40% stayed in hotels, 32% in the hospital, while 16% of the patients with their relatives. Among those who stayed in the hospital, 65% were satisfied, 23% were not satisfied and for 12% it was excellent (Sajjad, 2009; Anvekar, 2012).

Out of the 54 international patients interviewed, 19 patients found the food served at the hospital "different, little spicy but ok". For 16 patients, the food was decent, while for 3 patients, it was excellent; 6 patients found the food dissatisfactory and 2 were having fruits only. Six patients didn't have food in the hospital. While 19(35.2%) foreign patients found the food served at the hospital excellent or decent, the remaining 35 (64.8%) patients found the food not satisfactory (Table 3. 50). However, according to the hospital staff, special dietary was provided to the foreign patients in all the hospitals we visited, excepting LV Prasad Eye Institute. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 91

Table 3.50: Quality of Food served at the Hospital Sl.No. Quality of food Percentage 1. Excellent 3 (5.6%) 2. Decent 16 (29.6%) 3. Dissatisfactory 7 (13.0%) 4. It's a challenge, they provide what is asked like boiled potato, tomato soup 1 (1.8%) 5. Not had food in the hospital 6 (11.1%) 6. Different, little spicy but ok 19 (35.2%) 7. Having fruits only 2 (3.7%) Total 54 (100%) A study by Anvekar in respect of 5 major hospitals in Bangalore, also shows that a large number of international patients (76%) were not satisfied with the food served by the hospital, only 18% were satisfied and for 6%, the food was excellent (Anvekar, 2012). However, a study by Sajjad reveals that all the foreign patients were satisfied with the food served at the hospital (Sajjad, 2009).

Table 3.51: Whether Patients had Received any prior Information about their Discharge Sl.No. Information about discharge Percentage 1. Yes 10 18.5% 2. No 3 5.6% 3. Still continuing with treatment 35 64.8% 4. Not yet discharged 6 11.1% Total 54 100% CESS Monograph - 42 92

When enquired whether they had received any prior information about their discharge from the hospital, 10 (18.5%) patients replied in affirmation, while 3 (5.6%) said 'no'. Those who were still continuing with the treatment (64.8%) did not have any information, while 6 (11.1%) were yet to be discharged (Table 3. 51). Table 3.52: Whether the Doctor had Prescribed Any Medicine Post their Treatment Sl.No. Whether medicine prescribed by doctor Percentage 1. Yes 5 9.3% 2. No 9 16.7% 3. Not yet over 38 70.3% 4. Not necessary 2 3.7% Total 54 100% Out of 54 patients, for 38 (70.3%) patients, the treatment was not yet over. The doctor had prescribed medicine for 5 (9.3%) patients, while in the case of 9 (16.7%) patients, no medicines had been prescribed and in the case of 2 (3.7%) patients, no medicine was necessary (Table 3. 52).

Table 3.53: Availability of medicines in their Country for those Medicines had been prescribed Sl.No. Availability of medicine in their country Percentage 1. Only in a few places 1 20% 2. Haven't checked 1 20% 3. Hospital provides for 1 month 2 40% 4. Not available 1 20% Total 5 100%

When asked where in their country were the prescribed medicines available, 42 did not respond; 5 patients had not bothered to check, while 3 patients said the medicines were Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 93 available only in a few places. And 2 patients responded that the hospital would provide medicines for one month (Table 3. 53).

Table 3.54: Whether the Alternate of the Medicine Prescribed Available in Your Country Sl.No. Alternate of medicine available Percentage 1. Yes 0 2. Not Available 1 20% 3. Will take from India 4 80% Total 5 100% When asked whether an alternate of the medicine was available in their country, 4 patients responded that they would take the medicine prescribed by the doctor from India, while one said that it was not available (Table 3. 54). Table 3.55: Will You Come Here For Follow up Treatment? Sl.No. Coming for follow up treatment Percentage 1. Yes 51 94.4% 2. No 2 3.7% 3. Can be done in our country 1 1.9% Total 54 100%

Out of the 54 international patients interviewed in Hyderabad, an overwhelming 51 (94.4%) patients responded that they would come for follow up treatment, while 2 (3.7%) said 'no' and 1 (1.9%) patient was of the opinion that the follow up treatment could be done in their country (Table 3. 55).

However, in a study conducted in Delhi, a majority of the foreign patients (67.4%) said that they would refer to telemedicine, 18.2% said they would come for follow up checkup, 9.8% said that they would consult through e-mail and in the case of 4.5% of the patients, follow up was not required (Sajjad, 2009). CESS Monograph - 42 94

Table 3.56: Would You Come Here in Future if You Need Any Treatment Sl.No. Coming here in the future Percentage 1. Yes 53 98.1% 2. No 1 1.9% Total 54 100% Out of 54 international patients, 53 (98.1%) said that they would come here in future if they needed any treatment. Only 1 patient said that he would not come for treatment in the future (Table 3. 56). The study reviewed also shows the same result. A majority of the medical tourists would come back to the hospital, if required in the future.

Table 3.57: Would You Like to Suggest to Others this Hospital in Your Country? Sl.No. Would suggest others Percentage 1. Yes 53 98.1% 2. No 1 1.9% Total 54 100% A majority of international patients i.e., 53 (98.1%) out of 54, said that they would recommend this hospital to others in their country. Only 1 patient said that he would not suggest the hospital to others (Table 3. 57). According to the hospital personnel, of all the hospitals we visited, there has been a gradual growth over the years in the number of international patients coming for treatment. Similar findings have been seen in the studies reviewed. A study by Sajjad reveals that 92.4% of the patients said they would tell their friends and relatives about the hospital, while only 3% were unsure and 4.5% had already told their friends and relatives about the hospital. According to a study by Reddy, an overwhelming number (94.1%) of foreign patients would recommend medical tourism to friends and family members based on their experience in India (Sajjad, 2009; Reddy, 2013). A study by Sunita Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 95

Maheswari shows that up to one-quarter of the respondents had expressed regret and that they would not recommend India to their friends and colleagues, while two-thirds would still recommend Indian hospitals to others (Maheshwari et al, 2012). 3.5: Ethical Issues Medical Tourism, however, runs the risk of facing many ethical problems. The very idea of people travelling from rich countries to a poor country like India to exploit the resources there gives rise to many ethical issues. The growing disparity between the rich and the poor has made the commodification of organs an attractive business proposition for some, while a solution for others. The ethical problems may include illegal organ trading and surrogacy. Illegal organ trading is on the rise in Andhra Pradesh. Illegal organ trading may include the selling of organs like kidney, lungs, liver etc. According to the state police, kidney sale racket has increased in Andhra Pradesh with some of the leading hospitals involved. It is rampant in coastal areas of Vijayawada, Rajahmundry, Kakinada and Visakhapatnam. Discussed below are a few cases of illegal kidney transplantation in Andhra Pradesh, based on newspaper reports. Poor migrants from the east and northeast India and refugees constitute the Kidney donors. People from the east and northeast India and refugees from Bangladesh, who come to the state's coastal towns of Vijayawada, Rajahmundry, Kakinada and Vishakhapatnam for jobs, are easy to approach by brokers. They are roped in on special Kidney-sale-cum-tourism packages. According to the state police, kidney sale racket has increased in Andhra Pradesh over the years with some of the leading hospitals involved. Nearly 400 kidney transplants have been reported conducted during 2003 of which nearly 70% were illegal. These transplants have been carried out in various hospitals in Hyderabad, Vijayawada, Visakhapatnam and Rajahmundry. The Andhra chapter of the Indian Medical Association reveals that refugees from Eastern India account for 40% of the Kidney transplants in the state (Health, 2003). In Hyderabad, a kidney racket has been busted by the police arresting 4 persons in the case. The patients and donors were lured by agents with the help of social media. While the patients and donors belonged to India, the surgeries were conducted abroad in hospitals in Sri Lanka and Iran. The agents would not let the recipients and donors connect with each other and share their details. They were taken to these countries on a tourist visa, and in the case of Sri Lanka, the visa was given on arrival. The Transplantation of Human Organs Amendment Act, 2011, which was notified in early CESS Monograph - 42 96

2014, clearly prescribes very stringent punishments with respect to commercial dealing in human organs (Sekhar, 2015). Another ethical issue, which is becoming an attractive business proposition, is surrogacy, a system in which a couple hires the womb of another woman to bear their child. India legalized commercial surrogacy in 2002. In view of the low cost of infertility treatment in India and with modern assisted reproductive techniques (ARTs) available here, India has become a top choice for infertility treatment. Discussed below is a case of surrogacy in the town of Guntur in Andhra Pradesh. In Andhra Pradesh, this rent-a-womb trend has been on the rise in the poverty stricken town of Guntur. Irrespective of the norms and health parameters, several women from the underprivileged sections are lured by agents in to renting their wombs. The agents target generally the lower middle class women who are in dire need of money; Rs.2.5 lakh is paid to the surrogate mothers. In some cases, the surrogate mothers themselves become agents and try to convince their relatives into making use of the procedure to make money (Rao, 2012). However, there are no enough safeguards for surrogate mothers and children, according to a study. The study by Centre for Social research (CSR) among 100 surrogate mothers and 50 commissioning parents and their families in three cities of Gujarat, recommended for the formulation of a strong legal framework to address the issue of surrogacy in India.The potential surrogate mothers are not given a copy of the contract signed between the surrogate mother, the commissioning parents and the fertility physician as a result of which they may not come to know of the clauses of such contracts. Moreover, to ensure a high success rate, some surrogate mothers are impregnated without their knowledge. In some cases of unhealthy pregnancies, abortion pills are given by doctors for terminating pregnancy without the knowledge of the surrogate mother who thinks she has had a natural abortion. Again, most of the commissioning parents are from countries where surrogacy is illegal. Just because surrogate mothers are usually poor, illiterate or semi-literate, besides being in need of money, they are not able to understand the complex medical procedures their bodies are subjected to (Hindu, 2013; CSR, 2013). 3.6: Summary The above study clearly brings out the fact that though recent development, medical tourism in Hyderabad is slowly but surely becoming a hit owing to the many world class hospitals and experienced doctors in the city. The hospitals are well equipped with Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 97 modern amenities and well trained doctors who are also highly qualified. The city provides world class medical services at affordable rates. The hospitals employ translators so as to ease the language problems faced by international patients, particularly those from Arab countries who are not well versed in English. The background characteristics of the international patients coming to Hyderabad for treatment show that, more males are coming than females. Most of the patients are in the age group of 51-60 years of age with most of them married. Education-wise, most of the patients are either primary educated or graduates. There are a few illiterates also. Overall, male patients are more educated than female patients. Looking at the occupation of patients, nearly 30% are not working, while 15% are children. The rest are into various kinds of occupations. Among the family members of the international patients also, the number of males who are married is high as compared to females. Looking at the education level of the family members, it is evident that more or less, there is an equal distribution of members across all the categories. Medical Tourism includes the movement of people from one country to another mainly to avail of medical services which may be due to various reasons like doctors' specialization, long waiting time in their country, treatment being costly in their country or simply to visit another country as part of their treatment. In this study, more than half of the patients (55.6%) are from Africa followed by Middle East countries. Very few are from South Asia and North America and none from Europe. From Africa a majority are only from Nigeria. This may be due to the fact that Nigeria is among the top 25 trading partners of India even as India is Nigeria's largest export market. The health procedures for which international patients come to India for treatment are varied and diverse. This study shows that more patients come for cancer treatment followed by cardiac treatment. However, the dominance of patients in these two types of treatment may be due to the fact that most of the patients are from two specialized hospitals in cancer and heart. The most important reason for the patients coming to India for treatment is the specialization of doctors followed by a relatively low cost of treatment here in Hyderabad. In many cases, they had been told about the place and hospital by their friends and relatives. A few also had come to know about the hospital by doctors at their place. A very few had searched for the hospital on the website and none suggested by agencies and networks. However, the medium of contact with the doctors and hospital was mostly online and over the phone. Regarding the visa issue, a majority of the patients didn't face any problem. Only a few (14.8%) had some problem (in terms of delay) getting visa in that they had to go to CESS Monograph - 42 98

Embassy again and again before getting the visa. In some countries like Cameroon, since there is no embassy, the counselor has to go to Nigeria for visa because of which they charge double the money. And in some cases also, if the visa is urgent, they charge double the money. A few African patients also complained that the patients had not been treated properly by the staff at the embassy. Most of them had availed of medical visa, while a few had come with tourist visa and a few had both medical and tourist visas. One of the main reasons why people opt for medical tourism is that they are not covered or partially covered by insurance. The study also shows that a majority of the patients did not have health insurance. The expenses of the treatment ranged from a minimum of $ 29.91 to $ 23000. Medical Tourism includes two industries- health and tourism. However, the study reveals that more patients were not interested in visiting places or tourist spots as they wanted to go back home soon. Most of them had left their families behind and so wanted to go back as soon as possible, while a few wanted to visit only nearby places. A majority of the patients were from Africa. Considering that international patients from African countries are well versed in English, they do not face any problem with the language. However, patients from Middle East countries have to depend on interpreters provided by hospitals. The satisfaction level of international patients with the quality of care and relationship with doctors and staff of the hospital is an important parameter that influences the success of Medical Tourism. The international patients coming to Hyderabad for treatment are satisfied with the overall experience they have had from the hospital. They are willing to come even for follow up check-ups, if necessary. They would definitely recommend the hospital and doctors to their friends and relatives. A few have already told their friends and relatives about the hospital. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 99

4. Medical Tourism in Chennai

4.1 Introduction Tamil Nadu lies in the southern most part of the Indian peninsula. It covers an area of 130,058 sq km and is the eleventh largest state in India. The bordering states are Kerala to the west, to the North West and Andhra Pradesh to the north. To the east are the Bay of Bengal and the union territory of Puducherry. Tamil Nadu is famous for its wonderful temples and monuments built thousands of years ago and places that have been recognized as heritage sites by the United Nations. This state, with a rich historical importance, is also one of the fastest developing centres of technology and trade (Map 4.1).

Map 4.1: Tamil Nadu CESS Monograph - 42 100

4.1.1 A Demographic Profile of Tamil Nadu As per 2011 Census, Tamil Nadu is home to a population of 7.21 crore, an increase from 6.24 crores over 2001 Census. The total population of Tamil Nadu is 72,147,030 of which males and females constitute 36,137,975 and 36,009,055 respectively. Tamil Nadu has a population Density of 555 per sq km, which is higher than the national average of 382 per sq km. The literacy rate of the state is 80.09% of that male literacy is 86.77 percent and that of female 73.14 percent. The sex ratio of the state is 996 (Table 4. 1).

Table 4.1: A Demographic Profile of Tamil Nadu as per 2011 Census Particulars Tamil Nadu, 2011 Census Male Female Total Population 36,137,975 36,009,055 72,147,030 Density 555 Sex Ratio 996 Literacy rate 86.77% 73.14% 80.09% Source: Census, 2011

4.1.2 Tourism in Tamil Nadu Tamil Nadu is renowned for its temple towns and heritage sites, hill stations, waterfalls, national parks, fabulous wildlife and scenic beauty. There has been an increase in tourist arrivals in Tamil Nadu due to aggressive promotion and marketing campaigns through print and electronic media at the domestic, national and international levels as well as through the creation and upgradation of basic amenities and infrastructure at tourist spots. The state has the largest tourism industry in India with an annual growth rate of 16 percent. The number of tourists arrivals in the state rose by34.1 percent in 2012 to 187.6 million from 140 million in 2011 (Narasimhan, 2013). In 2013, the foreign tourist arrivals in the state was 0.39 million, the second highest in the country (Table 4. 1&Figure 4. 1).

Table 4.2:Foreign Tourist Arrivals in Tamil Nadu, 2010-2013 Year Numbers 2010 2804504 2011 3308438 2012 3561740 2013 3990490 Source; Department of Tourism, Govt. of India, 2013 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 101

Figure 4.1: Foreign Tourist Arrivals in Tamil Nadu, 2010-2013

Source: Department of Tourism, Govt. of India, 2013

4.1.3 Health Care in Tamil Nadu Health infrastructure in Tamil Nadu has been fairly good as compared to other states, and this has had a benefit in terms of relatively low costs for outpatient treatments. The world's leading medical journals have applauded Tamil Nadu's low-cost health care model for phenomenally reducing the infant mortality and maternal mortality between 1980 and 2005 (NDTV, 2013). Tamil Nadu has the best record in respect of full child immunisation coverage and the percentage of women receiving antenatal and postnatal care. The state demonstrated an excellent record in responding swiftly to the 2004 tsunami disaster in organising care for survivors and preventing epidemics from spreading (rediff.com, 2009). Tamil Nadu has some of the prominent hospitals like Apollo, , Harvey's superspeciality and SankaraNethralaya in Chennai and Arvind Eye Care and PSG Hospitals in Madurai and respectively, attracting patients from different parts of the country, as well as from the Middle East, Pakistan and Africa. According to the state's eleventh five year plan, the Tamil Nadu government planned to make the state a favoured domestic and international tourist destination by citing the availability of super speciality hospitals providing high quality services at affordable costs (Times, 2008). CESS Monograph - 42 102

4.2 Chennai Chennai is the capital city and also the largest city of Tamil Nadu. Chennai, sometimes, referred to as the "Gateway to South India," is located on the south-eastern coast of India in the north-eastern part of Tamil Nadu on a flat coastal plain known as the Eastern Coastal Plains. The city of Chennai has also been endowed with a rich heritage of art and culture (Map 4. 2). Map 4.2: Chennai

4.2.1 A Demographic Profile of Chennai According to the population results of 2011, Chennai has a population of 4,681,087, with 2,357,633 males and 2,323,454 females. The literacy rate of the city is 90.33 percent of which male literacy is 93.47 percent and female literacy is 87.16 percent. The sex ratio is 986 for every 1000 males (Table 4. 3). Table 4.3: A Demographic Profile of Chennai as per 2011 Census Particulars Chennai, 2011 Census Male Female Total Population 2,357,633 2,323,454 4,681,087 Sex Ratio 986 Literacy rate 93.47% 87.16% 90.33% Source: (Census, 2011) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 103

4.2.2 Tourism in Chennai Chennai, said to be the gateway to South Indian peninsula, is also a place of historic importance. It is a pulsating city, ever changing and ever expanding. The city is probably the most peaceful and green metropolis of India and is a blend of temples, churches, monuments and several other prime destinations. Its fascinating monuments and churches date back to the Portuguese and British periods with the spectacular stretching 13 km along the city's eastern flank which is a favourite place for the city dwellers and visitors. The Fort St. George is another widely visited spot of the city that depicts the colonial influence of British and Portuguese on the city. Major places of worship are Parthasarthi Temple, Kapaleeswarar temple, Wallajah mosque, "Thousand lights" mosque and San Thomas Basilica (GoTN Portal, 2013). Chennai has been the most visited city in India by foreign tourists (since 2008), overtaking New Delhi and Mumbai with visitors thronging the heritage sites in Kanchipuram and Mahabalipuram and medical tourists making up the largest numbers (TOI, 2010). However, the year 2012 witnessed a decline in the number of foreign tourists as shown in Table 4.4 and Figure 4.2. Table 4.4: Foreign Tourist Arrivals in Chennai from 2010 to2013 Years Numbers 2011 1159076 2012 708778 2013 794098 Source: Department of Tourism, Tamil Nadu, 2012& Economic Times, 2014

Figure 4.2: Foreign Tourist Arrivals in Chennai, 2011- 2013 CESS Monograph - 42 104

4.2.3 Healthcare in Chennai The city of Chennai has been termed India's health capital. Multi- and super-speciality hospitals across the city bring in an estimated 150 international patients every day. Healthcare in Chennai is provided by both government-run and private hospitals. Chennai attracts about 45 percent of health tourists from abroad arriving in the country and 30 to 40 percent of the domestic health tourists. Factors behind the tourists' inflow to the city include affordable costs, little-to-no-waiting period, and facilities offered at speciality hospitals in the city. The city has an estimated 12,500 hospital beds, of which only half are used by the city's population with the rest being shared by patients from other states of the country and foreigners. In addition, dental clinics attract dental care tourism in Chennai (TOI, 2011)..

There are 15 Government hospitals and a large number of private hospitals which provide medical and health care. The Government General hospital, popularly referred to as "G.H.", is the biggest government run hospital in the city. Some of India's well- known healthcare institutions such as Apollo Hospitals (the largest private healthcare provider in Asia), , Madras Medical Mission (MMM), Frontier Lifeline and K.M.Cherian heart foundation and Sri Ramachandra Medical Centre are based in the city, making it one of the preferred destinations for medical tourists from across the globe.

4.2.4 Medical Tourism in Chennai Chennai is the epicenter of India's medical tourism industry with its cheap healthcare, top-of-the-range medical technology and English speaking doctors.

Chennai attracts about 40 percent of the country's medical tourists with more than six lakh tourists visiting 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 percent, with Chennai continuing to be the favourite destination. The city receives up to 200 foreign patients every day owing to the quality of healthcare, as observed by S Chandrakumar, convener of the CII healthcare panel, at the international conference and exhibition on health tourism in (TOI, 2013).

Advantage of Medical Tourism in Chennai: ● Most medical tourists choose Chennai because of the low costs of health care with some procedures offered at just one-fifth of the price in the UK, often including airfare and accommodation during recovery. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 105

● The city is well connected to other Indian and global destinations, making it a relatively convenient option for Europeans seeking to combine medical care with a holiday.

● With the Globe's second-longest seashore, there are a plenty of close-by beaches on which to convalesce, as well as western-style malls and cinemas for entertainment.

● Chennai hospitals offer a wide range of procedures, with the most popular being heart surgery, followed by orthopaedic and eye surgeries. There are specialist hospitals for eyes, bones and joints, as also specialist clinics within the city hospitals catering to the likes of plastic surgery. Dental care in Chennai is also becoming popular for its attractive prices and everything from cosmetic procedures like teeth whitening to crowns and veneers are offered.

● Chennai hospitals offer a holistic service for patients, from airport pickups through to private chefs.

4.2.5: Accreditation of Hospitals The practice of accreditation assures that hospitals have specified infrastructure and systems in place, which are expected to help these hospitals deliver a high quality care. There are several quality standards to which hospitals are accredited. National Accreditation Board for Hospitals and Healthcare providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation and allied programs for healthcare organizations. Participation in NABH accreditation program is on a voluntary basis. National Accreditation Board for Testing and Calibration Laboratories (NABL) is more department-specific accreditation. There is also an international accreditation such as The Joint Commission International (JCI) that promotes business through medical tourism. International Organization for Standardization (ISO) is a non-governmental organization comprising representatives from various national standard organizations of 162 member countries. It ensures the quality, safety and efficiency of products, services and systems. Indian Health Organization (IHO) comprises high quality medical experts and service providers with an aim to making healthcare services affordable to all. HALAL certification means that the food provided has been certified that it does not contain any forbidden components according to the Islamic law (ISO, 2016). CESS Monograph - 42 106

Table 4.5: A List of Hospitals in Chennai SL. Name of the Accreditation No. of No. of No. of Medical No. Hospital of the hospital beds doctors paramedical tourism staff 1. Adyar Cancer Institute 423 2. Billroth hospitals 600 Yes 3. Madras Medical Mission, Institute of Cardiovascular Diseases 256 Yes 4. MIOT Hospitals ISO,IHO 1000 Yes 5. Dr. Kamakshi Memorial Hospital Pvt.ltd Yes 6. 600 Yes 7. Madras Medical Mission ISO 256 Yes 8. Global Hospitals NABH, NABL, 500 164 Yes HALAL 9. Sri Ramchandra Medical NABH, JCI >1500 Yes Centre 10. Fortis Malar NABH, ISO 180 160 58 Yes Source: www.southindia.com/hospitals in Chennai 4.3 Hospitals Visited for the Study Fortis Malar Hospital Fortis Malar Hospital, established in 1992, is one of the distinguished multi super- speciality corporate hospitals in Chennai providing a comprehensive medical care in the areas of cardiology, cardio-thoracic surgery, neurology, neurosurgery, orthopaedics, nephrology, gynaecology, gastroenterology, urology, pediatrics, diabetics and so on. The Hospital has a vast pool of talented and experienced team of doctors, who are further assisted by a team of highly qualified, experienced and dedicated support staff and with a cutting edge technology. Accreditation: The hospital has been accredited by NABH and ISO as it gives a high priority to patient safety and quality treatment. Facilities: Number of doctors- 125 Number of nurses-261 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 107

Number of paramedical staff- 58 Number of departments- 20 Number of beds- 180 Number of in-patients- 11000/year

Table 4.6: Hospitals visited for the Study Sl No Name of the Hospital No of patients Observations 1. Fortis Malar Hospital 10 Has a separate help desk for international patients. The patients come with a prior appointment so that they can see the doctor immediately. 2. Global Hospitals 22 There is a huge waiting room with enough seating arrangements and the patients have to wait before they are referred to the doctor. The hospital is very clean. 3. Sri Ramachandra Medical 12 Patients take a prior appointment to Centre meet the doctor and they have to wait for some time till their turn comes. The hospital is cleaned regularly. 4. Billroth Hospital 6 The cleanliness and hygiene of the hospital are well maintained with cleaners doing their job round the clock. The drug store and cafeteria is in the main building. Total 50

Separate wing for International Patients: The hospital has a department dedicated to International Patient Services which takes care of all healthcare and related requirements of patients and their attendants travelling to India. The international wing has 36 beds, 15 workers and 5 staff with 50 international patients being admitted, on an average, in a month. Countries of International patients: The medical tourists come from various countries like the USA, UK, Australia, Africa, UAE and Middle East. Age of International patients: International patients are of all age groups, starting from 1 day to 90+ years. CESS Monograph - 42 108

Special services provided by the medical tourism division: The medical tourism division provides various special services like online pre- operative counselling with the doctor, electronic transfer of medical records to and from the prospective medical tourists, arranging visa, tie-ups with insurance providers, translators, special dietary service, tie- ups with travel agencies for tourism interests of medical tourists and accommodation for companion/s of the medical tourists. Global Hospitals Global Hospitals is India's premier chain of multi-speciality tertiary healthcare. The chain has pioneered several cutting-edged and advanced procedures in Multi-Organ Transplants such as kidneys, liver, heart and lungs. Global Hospitals is famous across the world for its state-of-the-art infrastructure, quality care and treatment, and exceptional services. The hospital is equipped with India's largest Multi-Organ Transplant Centre and employs the country's foremost team of experts in a host of specialties. Accreditation: The hospital has been accredited by NABH, NABL and HAlAl. Facilities: Number of doctors: 164 Number of departments: 30 Number of beds: 500 Separate wing for International Patients: There is no separate help desk for international patients, though there is a staff near the help desk to look after the needs of international patients. Countries of International patients: The hospital also attracts a wide number of patients from across the globe - Middle-East, Africa, South Asia being primary pockets of interest. Age of International patients: International patients of all age groups come for treatment. Sri Ramachandra Medical Centre Sri Ramachandra Medical Centre (SRMC) is a tertiary care multi-speciality hospital. The medical centre was founded as a teaching hospital of Sri Ramachandra Medical College and Research Institute in 1985, with the intention of translating the experience and expertise in medical education into a tangible and affordable health care to the community. Accreditation: To ensure the quality of treatment, the hospital has been accredited by NABH and JCI. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 109

Facilities: Number of beds- 692 Number of Intensive care units (ICUs) - 171 Educational activities- Happens regularly on a weekly basis. Separate wing for International Patients:The centre has an International Patients Care and Services department known as International Patients Facilitation Center to cater to the needs of international patients from across the world - including those from the advanced nations of the west for over a decade. Countries of International patients: Most of the patients are from Africa (Nigeria, Tanzania, Kenya), Middle East (Iraq, Muscat) and South Asia (Bangladesh and Sri Lanka). Age of International patients: The international patients are mostly in the age group of 40-50 years. Special services provided by the medical tourism division: The medical tourism division provides various special services like online pre- operative counselling with the doctors, electronic transfer of medical records to and from the prospective medical tourists, arranging for visa, tie-ups with insurance providers, translators, Special dietary service, tie-ups with travel agencies for tourism interests of medical tourists and accommodation for companion/s of the medical tourists. Average number of international patients in a year: The number of international patients over the year has increased starting from 25 per month in the year 2010 to 60 per month as of 2013. Billroth hospital Billroth hospital is a super speciality hospital in Chennai launched in the year 1990. Its main aim is to provide quality and efficient medical services in the most professional and effective manner, with the sole determination of making things better for patients. The team comprises medical professionals with experience and expertise in specialized medical practices. The dedicated team also has a great experience and familiarity in international methods and practices.With the most modern facilities, state-of-the-art equipment and complete comfort, Billroth also has International Patient Service. Facilities: Number of beds- 600 Educational activities: The hospital undertakes/organizes educational activities like lectures, conferences, seminars and workshops. CESS Monograph - 42 110

Separate wing for International Patients: There is a separate wing (building) for the international patients with a separate help desk. The international wing has a different set of staff. Countries of International patients: Foreign patients mostly come from Africa, UAE, Maldives and Mauritius, with 165 foreign patients coming in the year 2013. Special services provided by the medical tourism division: The medical tourism division provides various special services like electronic transfer of medical record to and from the prospective medical tourists, arranging for visa, tie-ups with insurance providers, translators, special dietary service, tie-ups with travel agencies for tourism interests of the medical tourists and accommodation for companion/s of the medical tourists. 4.4 Study of International Patients This section is based on the data collected from international patients from a few hospitals in Chennai. An attempt has been made to have an idea about the reasons why international patients choose to come to India for treatment; to have an idea about their travel and treatment expenses; and to look into the satisfaction level of patients with regard to the quality of care and relationship with doctors and staff in the hospital. 4.4.1: Background Characteristics of International Patients This section examines the background characteristics of international patients like gender, age, marital status, literacy, country of the patient and his/her health problems.

Table 4.7: Gender Distribution of International Patients Sl.No. Sex Percentage 1. Male 34 68% 2. Female 16 32% Total 50 The table shows that, among the international patients coming for treatment, more were males. Out of 50 international patients in Chennai, 34 (68%) were males and 16 (32%) females (Table 4. 7). Studies conducted earlier also show that more male patients come for treatment than females. According to a study conducted among 72 foreign patients in Chennai city, 58.3% were males and 41.7% females (Sujatha & Subhashini, 2015). Several other studies also reveal that more men were coming to India for treatment than females Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 111

(Prakash et al, 2011; (Anvekar, 2012; Dhodi, Uniyal, & Sharma, 2014; Gupta et al, 2015). However, a few other studies also show that more females had come than males for treatment (Sajjad, 2009; Maheshwari, Animasahun, & Njokanma, 2012).

Table 4.8: Distribution of International Patients by Age Group Sl.No. Age Group (in years) Percentage Male Female Total 1. upto-10 3 0 3 100% 6% 2. 11-20 2 0 2 100% 4% 3. 21-30 2 3 5 40% 60% 10% 4. 31-40 7 8 15 46.7% 53.3% 30% 5. 41-50 8 1 9 88.9% 11.1% 18% 6. 51-60 10 3 13 76.9% 23.1% 26% 7. 61-70 2 1 3 66.7% 33.3% 6% Total 34 16 50 68% 32% 100% An age-wise distribution of the international patients shows that most patients were less than 50 years (68%). There were 3 (6%) child patients, below 10 years, who were only boys. Out of 50 international patients interviewed in Chennai, 24 (48%) were in the age group of 31-50 years. Out of 24 patients, 15 (62.5%) were males and 9 (37.5%) females. Thus, 58% of the patients were in the category of 20-50 years. In the category of 51-70 years, there were 16 (32%) patients (Table 4. 8). The hospital questionnaire reveals that patients from all age groups came for treatment to Fortis and Global Hospitals. However, according to the hospital personnel in Sri Ramchandra Medical Centre, the average age group of foreign patients was 40-50 years. As per a study conducted by Sujatha & Subhasini among 72 foreign patients in Chennai city, most of the respondents were in the age category of 18-25 years (Sujatha & Subhashini, 2015). CESS Monograph - 42 112

Table 4.9: Distribution of International Patients by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 26 11 37 70.3% 29.7% 74% 2. Unmarried 8 5 13 61.5% 38.5 26% Total 34 16 50 68% 32% 100% The above table reveals that more patients were married than unmarried. Out of 50 international patients in Chennai, 37 (74%) were married and 13 (26%) unmarried. Among the married patients, 26 (70.3%) were males and 11 (29.7%) females. And among the unmarried patients, 8 (61.5%) were males and 5 (38.5%) females (Table 4. 9). Similarly, a study conducted among 72 international patients, shows that 38.9% were married and 30.6% were unmarried (Sujatha & Subhashini, 2015).

Table 4.10: Education-Wise Distribution of International Patients Sl.No. Level of Schooling Percentage Male Female Total 1. Primary 7 5 12 58.3% 41.7% 24% 2. Secondary 8 5 13 61.5% 38.5% 26% 3. Graduate 16 3 19 84.2% 15.8% 38% 4. Post Graduate/MBA 1 2 3 33.3% 66.7% 6% 5. Illiterate 2 1 3 66.7% 33.3% 6% Total 34 16 50 68% 32% 100%

The educational status of the respondents shows that 19 (38%) were graduates, 13 (26%) secondary educated and 12 (24%) primary educated. A very few were post graduates i.e., 3 (6%) and 3 (6%) illiterates. Among the graduates, 16 (84.2%) were males and only 3 (15.8%) females. Among the post graduates, more were females (66.7%) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 113 than males (33.3%). Among the illiterates, more were males (66.7%) than females (33.3%).Thus, the above data shows that a majority of the patients were in the graduate category (Table 4.10).

Table 4.11: Occupation-Wise Distribution of International Patients Sl.No. Occupation Percentage Male Female Total 1. Business 19 3 22 86.4% 13.6% 44% 2. Private job 2 1 3 66.7% 33.3% 6% 3. Student 3 1 4 75% 25% 8% 4. Teacher 0 1 1 100% 2% 5. Child 3 0 3 100% 6% 6. Not working 4 10 14 28.6% 71.4% 28% 7. Event Planner 1 0 1 100% 2% 8. Farmer 1 0 1 100% 2% 9. Taxi Driver 1 0 1 100% 2% Total 34 16 50 68% 32% 100%

The above table reveals that more patients (58%) were engaged in various kinds of jobs, while 34% were either not working or children and the rest 8% were students. Various occupations of the patients show that, 22 (44%) were into business, out of which 19 (86.4%) were males and 3 (13.6%) females. There were 14 non-working (28%) patients, out of which 10 (71.4%) were females and 4 (28.6%) males. Among the 4 students who had come for treatment, 3 (75%) were males and 1 (25%) female. And 3 children were males (Table 4.11). A study by Sujatha and Subhasini shows that, 38.9% were in the civil servant category while 25% were self-employed. In terms of income status, 52.8% earned below 500 $ and they visited Chennai for the purpose of business (Sujatha & Subhashini, 2015). CESS Monograph - 42 114

4.4.2: Background Characteristics of Family Members of International Patients This section examines the demographic details of the family members of international patients like sex, marital status and occupation.

Table 4.12:Age-wise Distribution of Family Members Sl.No. Age Group (in years) Percentage Male Female Total 1. upto-10 5 0 5 100% 4.2% 2. 11-20 3 2 5 60% 40% 4.2% 3. 21-30 9 4 13 69.2% 30.8% 11% 4. 31-40 28 18 46 60.9% 39.1% 39% 5. 41-50 17 9 26 65.4% 34.6% 22% 6. 51-60 15 4 19 78.9% 21.1% 16.1% 7. 61-70 3 1 4 75% 25% 3.4% Total 80 38 118 67.8% 32.2% 100% An age-wise distribution of family members of the patients shows that 46 (39%) were in the 31-40 years category, 26 (22%) in the 41-50 years category, and 19 (16.1%) in the 51-60 years category. Only 4 (3.4%) were in the 61-70 years category. Up to 20 years of age, there were 20 (16.9%) members. Thus, among the family members of international patients also, more were below 50 years of age than above 50 years (Table 4.12). Table 4.13: Distribution of Family Members by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 60 30 90 66.7% 33.3% 76.3% 2. Unmarried 20 8 28 71.4% 28.6% 23.7% Total 80 38 118 67.8% 32.2% 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 115

Among the family members, 90 (76.3%) were married and 28 (23.7%) unmarried. Among the married members, 60 (66.7%) were males and 30 (33.3%) females. Also among the unmarried members, there were more males 20 (71.4%) than females 8 (28.6%) (Table 4.13).

Table 4.14: Education-Wise Distribution of Family Members Sl.No. Level of Education Percentage Male Female Total 1. Primary 10 6 16 62.5% 37.5% 13.5% 2. Secondary 20 12 32 62.5% 37.5% 27.1% 3. Graduate 43 7 50 86% 14% 42.4% 4. Post Graduate/MBA 3 7 10 30% 70% 8.5% 5. Illiterate 4 6 10 40% 60% 8.5% Total 80 38 118 67.8% 32.2% 100% The education status of the family members unfolds that, almost 50 (42.4%) were graduates, 32(27.1%) secondary educated, 16 (13.5%) primary educated, 10 (8.5%) post graduates and 10 (8.5%) illiterates. Among the graduates, there were more males, 43 (86%) than females, 7 (14%). While out of 10 illiterates, 6 (60%) were females and 4 males (40%) (Table 4.14). The below table 4.15 reveals that most of family members of international patients were self-employed (44.1%), followed by 33.9% dependent members and 22% professionals/employees. Business was done by 86.6% of the members who were self- employed, out of which 40 (88.9%) were males and 5 (11.1%) females. The self-employed category also included 5.8% of farmers and 7.6% with Petrol Company. Among the professional/ employee members, 50% were engaged in private jobs. Rest of the members in the professional/employee category were engaged in other jobs such as accountant, engineer, teacher, marketing, event planner, electrician, medical staff, taxi driver and banking management. The dependent members included 67.5% who were not working, out of which 21 (77.8%) were females and only 6 (22.2%) males. There were 8 (20%) students among the dependent members, out of which 5 (62.5%) were males and 3 (37.5%) females, and also 12.5% male children (Table 4.15). CESS Monograph - 42 116

Table 4.15:Occupation-wise Distribution of Family Members Sl No Occupation Percentage Male Female Total 1 Self employed Business 40 5 45 88.9% 11.1% 86.6% Farmer 2 1 3 66.7% 33.3% 5.8% Petrol company 4 4 100% 7.6% Sub -Total 46 6 52 88.5% 11.5% 44.1% 2 Professionals/Employee Accountant 0 1 1 100% 3.8% Engineer 0 1 1 100% 3.8% Private job 11 2 13 84.6% 15.4% 50% Teacher 1 3 4 25% 75% 15.6% Marketing 1 0 1 100% 3.8% Event Planner 1 1 2 50% 50% 7.8% Electrician 1 1 100% 3.8% Medical Staff 1 1 100% 3.8% Taxi Driver 1 1 100% 3.8% Banking Management 1 1 100% 3.8% Sub -Total 18 8 26 69.2% 30.8% 22% 3 Dependent Child 5 0 5 100% 12.5% Student 5 3 8 62.5% 37.5% 20% Not working 6 21 27 22.2% 77.8% 67.5% Sub -Total 16 24 40 40% 60% 33.9% Grand Total 80 38 118 67.8% 32.2% 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 117

Table 4.16: Country-wise Distribution of International Patients Sl.No. Region Countries Percentage Male Female Total 1. Africa Nigeria (West Africa) 3 1 4 Tanzania (East Africa) 1 1 2 Kenya (East Africa) 2 5 7 Somalia (East Africa) 1 1 2 Djibouti (East Africa) 5 5 (East Africa) 1 1 Sudan (North Africa) 2 2 Total 15 8 23 65.2% 34.8% 46% 2. Middle East Countries Oman 11 6 17 Iraq 4 2 6 Bahrain 1 1 Total 16 8 24 66.7% 33.3% 48% 3. South Asia Bangladesh 1 Sri Lanka 1 Maldives 1 Total 3 3 100% 6% Total 34 16 50 68% 32% 100% The above data reveals that 24 (48%) patients were from Middle East, followed by 23 (46%) from Africa. Out of 24 patients from the Middle East, 66.7% were males and 33.3% females. From Africa also, there were more males (65.2%) than females (34.8%).Only 3 (6%) were from South Asia and all were males. Thus, in Chennai, relatively more patients came from Middle East countries followed by patients from Africa (Table 4.16). The foreign patients in the present study came from Africa, Middle East and South Asia. However the hospital questionnaire reveals that in Fortis Malar Hospital, there were foreign patients also from USA, UK, Australia along with Africa and Middle East, while in Sri Ramchandra Medical Centre, there were patients also from Bangladesh and Sri Lanka apart from Africa and Middle East. According to , foreigners especially from the developing and under-developed countries such as Nigeria, Kenya, Burundi, Congo, Bangladesh, Oman and Iraq come CESS Monograph - 42 118

Table 4.17: Health Problems of International Patients Sl.No. WHO Classification of Diseases Health Percentage Problems Male Female Total 1. Infections and Parasitic Diseases HIV 2 1 3 ENT 66.7% 33.3 6% 2. Neoplasm Cancer 2 2 4 50% 50% 8% 3. Diseases of Nervous System Neurological 4 4 8 problems 50% 50% 16% 4. Diseases of Circulatory System Cardiac 7 2 9 77.8% 22.2% 18% 5. Diseases of the Digestive System Liver Problem 6 0 6 100% 12% Gastro Intestinal 1 0 1 100% 2% 6. Diseases of the Musculoskeletal Orthopaedic 1 2 3 System and Connective Tissue 33.3% 66.7% 6% 7. Diseases of Genitourinary System Urology 3 0 3 100% 6% Gynaenocology 0 2 2 100% 4% Kidney Problem 4 1 5 80% 20% 10% Endometric cyst 0 1 1 100% 2% 8. Endocrine, Nutritional and Sugar Problem 0 1 1 Metabolic diseases 100% 2% 9. Others Master check up 1 0 1 100% 2% Plastic Surgery 2 0 2 100% 4% Physiotherapy 1 0 1 100% 2% Total 34 16 50 68% 32% 100% to the city of Chennai for Medical treatment. Arab patients feel at home here as a number of restaurants serve their food here (The Hindu, Retrieved 16th Sept 2012). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 119

However, a study carried out across various hospitals in Chennai with 200 beds shows that 25.69% of the medical tourists came from USA, 19.27 % from Middle East and 15.60% from UK (Pougajendy & R.Senapathi, 2012). An examination of the health problems of international patients shows that patients having various health problems came to Chennai for treatment with the highest being 9 (18%) patients with cardiac problems followed by 8 (16%) patients with neurological problems. Among the patients suffering from cardiac problems, 7 (77.8%) were males and 2 (22.2%) females, while an equal number of males and females had neurological problems (4 each). International patients had also come with other health problems like liver, kidney, urological, gynaecological, orthopaedic, and cancer as well. There was 1 patient each for plastic surgery and physiotherapy also (Table 4.17). 4.4.3: Reasons for coming to India This segment examines the reasons for which international patients choose to come to India for treatment. Patients opting for medical tourism may choose a particular country which they believe can give them the best doctors and best facilities. Non Resident Indians (NRI) opt to come to India because they have their families here and also because their overall trip cost will be less as they are more likely to stay with their families.

Table 4.18: Reasons for Choosing India for Treatment Sl.No. Reasons Percentage 1. Low cost 24 48% 2. Specialized doctors 49 98% 3. Long waiting time in your country 2 4% 4. Treatment not available in your country 6 12% 5. Better technology and treatment 2 4% 6. Good hospital 1 2% Total 84 168% Note: Due to multiple answers, the aggregate percentage may exceed 100 CESS Monograph - 42 120

For most of the international patients (98%), the professional expertise of doctors was the main reason behind choosing Chennai for treatment, as also low cost for 48% of the patients. For 12% of the patients, treatment was not available in their country. And only 4% had come because of the long waiting time in their country and also because of the availability of a better technology and treatment in India (Table 4.18). According to some studies the most important reason for medical tourism is the professional expertise of doctors, an aspect highlighted by our study also. This is followed by the relatively low cost of treatment in India which is an important reason for medical tourism. The non-availability of certain specific treatments in their own country also influences medical tourists to come to India for treatment. Less waiting time is another significant factor for choosing India for treatment (Reddy, 2013; Gupta et al, 2015). Table 4.19: Who Suggested this Place and Hospital Sl.No. Who suggested the place Percentage 1. Friends /relatives 30 60% 2. Doctors at your place 23 46% 3. Website 1 2% 4. Network/Agencies 2 4% 5. Ministry 1 2% Total 57 114% Note: Due to multiple answers, the aggregate percentage may exceed 100) The above data reveals that a majority of the patients (60%) had come to know of the place (Chennai) and hospital from their friends and relatives, while 46% had been referred by the doctors at their place. A very few (4%) had come to know of the place and hospital from agencies and only 2% from the website (Table 4.19). Earlier studies also reveal that it was through personal recommendations of friends and relatives that the medical tourists had come to know of India and the hospital as also from doctors and hospitals in the home country. Internet is also another medium by which the medical tourists had come to know about the hospital. Having family in the Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 121 city could also be a reason for international patients to choose the hospital (Prakash et al, 2011;Maheshwari et al, 2012; Reddy, 2013; Padiya & Goradara, 2014; Gupta et al, 2015). However, a study by Pougajendy & Senapathi reveals that 23.33% had looked for agencies having tie-ups with hospitals , 20% had came to know of the hospital from advertisements and 16.67% from word-of-mouth (Pougajendy & R.Senapathi, 2012).

Table 4.20: Medium of Contact with the Hospital Sl.No. Medium of Contact Percentage 1. Online 30 60% 2. Over the phone 31 62% 3. Through friends who stay here 4 8% 4. Government arranged everything, we had to just come here 1 2% 5. Doctor 1 2% Total 67 134% Note: Due to Multiple answers, the aggregate percentage may exceed 100. On being asked the medium of contact with the hospital, 31 (62%) of the international patients reported that they had contacted the hospital over the phone, while 60% had been in touch with the hospital online. Some of the patients also had contacted the hospital through friends staying here and in case of 2% of the patients each, the government and the doctor had arranged for everything (Table 4.20). Online counselling and electronic transfer of medical records are also available for foreign patients in Sri Ramachandra Medical Centre and Fortis Malar Hospital. An overwhelming 98% of the international patients were attracted by the doctors' specialization, while 24% had chosen the hospital because of the low treatment charges. Infrastructure and hospitality of the hospital also attracted 22% of the patients to the hospital for treatment. Only 2% of the patients pointed out accommodation as one of the reasons for choosing the hospital (Table 4. 21). CESS Monograph - 42 122

Table 4.21: Facilities that Attracted the International Patients to this Hospital Sl.No. Facilities Percentage 1. Doctors' Specializaion 49 98% 2. Treatment charges 12 24% 3. Infrastructure 11 22% 4. Accommodation 2 4% 5. Hospitality 11 22% Total 85 170% Note: Due to multiple answers, the aggregate percentage may exceed 100. An earlier study by Poonam Gupta in Delhi NCR also shows that the profile of the doctors was the most important factor (43%) in the selection of the hospital and the quality of medical procedures (36%). Brand name of the hospital and the advice of family members and friends were also the factors that had influenced the choice of the hospital (Gupta et al, 2015). The quality of the services provided at the hospital, ease of travel to the place and long waiting time in their country also were responsible for attracting the international patients to the hospital (Sajjad, 2009).

Table 4.22: Difficulties Faced in Their Country Sl.No. Difficulties in their country Percentage 1. Disease not being diagnosed properly 17 34% 2. Non availability of specialists 35 70% 3. Delays in getting appointments 1 2% 4. Due to lack of insurance not being treated 1 2% 5. It is much expensive in terms of price 13 26% Total 67 134% Note: Due to Multiple answers, the aggregate percentage may exceed 100. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 123

When asked about the difficulties faced in their country because of which they had come to India for treatment, 35 (70%) of the foreign patients responded that it was due to the non-availability of specialists for treatment. In the case of 17 (34%) of the patients, the disease was not properly diagnosed and for 13 (26%) patients, the treatment was very expensive. Only 1 (2%) patient had come due to delays involved in getting appointments in their country (Table 4.22).

4.4.4: Visa This section deals with the patients' experience while applying for visa and obtaining it. Three most important variables governing visa experiences are availability of visa, cost and time taken in obtaining it.

Table 4.23: Any Difficulty faced while Applying for Visa Sl.No. Any difficulties Percentage 1. Yes 2 4% 2. No 47 94% 3. Lifelong visa/Overseas Citizenship of India(OCI) 1 2% Total 50 100%

Regarding any difficulties faced while applying for visa, an overwhelming 47 (94%) of the patients responded that they had not faced any difficulties, while 2 (4%) of the patients had some difficulties while applying for visa and only 1 (2%) patient had overseas citizenship of India (OCI) (Table 4. 23).

Among the special services provided by the hospitals - Fortis Malar Hospital and Sri Ramchandra Hospital - included the arrangement of visa and passport.

However, one of the research studies reveals that, many patients were unhappy about corruption, time taken and cost for treatment. This is an area which requires an immediate attention from our policy makers and government (Gupta et al, 2015). CESS Monograph - 42 124

Table 4.24: Whether the Staff at the Indian Embassy Friendly and Helpful Sl.No. Whether staff at the Embassy friendly Percentage 1. Yes 49 98% 2. No 0

3. Didn't deal with the embassy 1 2% Total 50 100%

Out of the total 50 international patients, 49 (98%) had found the staff at the Indian Embassy friendly and only 1 (2%) patient didn't have to deal with the embassy as he had OCI (Table 4.24).

Table 4.25:Distribution of Patients by Type of Visa Sl.No. Type of visa Percentage 1. Medical visa 40 80% 2. Tourist visa 4 8% 3. Medical & Tourist Visa 5 10% 4. OCI 1 2% Total 50 100%

Out of the total 50 international patients, a majority 40 (80%) had medical visa, while 5 (10%) had both medical and tourist visas. Some patients had only tourist visa (8%) and 1 patient OCI (Table 4.25). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 125

Table 4.26: How Many Days did you Get the Visa For Sl.No. Number of days Percentage 1. 2 months 6 12% 2. 3months 6 12% 3. 4 months 1 2% 4. 6 months 33 66% 5. 15 days 2 4% 6. 10 days 1 2% 7. Indian Citizen/lifelong citizen/OCI 1 2% Total 50 100%

Out of the 50 international patients, 33 (66%) had got visa for 6 months, 6 (12%) each for 2 and 3 months. Patients having visa for 4 months and 10 days constituted only 2% and 1 patient had OCI (Table 4.26). 4.4.5: Medical and Travel Expenses This segment examines the medical and travel expenses of international patients, and whether they had planned to do some tourism, while being in India. 4.4.5a: Insurance Insurance companies play an important role in promoting medical tourism. Some insurance companies offer incentives to patients who are willing to go abroad for treatment. The below table reveals that people come to India for treatment even without insurance. Among the respondents, 46 (92%) said they did not have insurance, only 3 (6%) had insurance, while in the case of one patient, the treatment was sponsored by his/her government (Table 4.27). CESS Monograph - 42 126

Table 4.27: Do They Have Health Insurance? Sl.No. Whether having health insurance Percentage 1. Yes 3 6% 2. No 46 92% 3. Sponsored by government 1 2% Total 50 100%

Most of the international patients didn't have health insurance. However, Fortis Malar Hospital and Sri Ramchandra Hospital have tie-ups with insurance providers to aid foreign patients in getting health insurance.

The studies reviewed also show that, most of the patients were self supported (Prakash et al, 2011) (Gupta et al, 2015).

Table 4.28: Would they have been able to come to India without Health Insurance? Sl.No. Whether able to come without health insurance Percentage 1. Yes 1 33.3% 2. No 2 66.6% Total 3 100%

In Chennai, out of the 3 patients who had insurance, only 1 patient would have been able to come to India even without insurance, while 2 patients would not have been able to come without insurance (Table 4.28). According to a study by Reddy, among 34 patients from hospitals in Bangalore, Hyderabad and Chennai, all excepting one patient answered that they would have been able to come to India even if their health insurance did not cover the trip (Reddy, 2013). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 127

Table 4.29: Did Health Insurance give any Additional Incentive to Come to India? Sl.No. Additional incentives of health insurance Percentage 1. Yes 0 2. No 3 100% Total 3 100% All the 3 patients in Chennai, who had come with health insurance, said that their health insurance didn't give any additional incentive to come to India (Table 4.29). 4.4.5b: Expenditure

Table 4.30: Cost of Treatment and Stay Place Reasons Number Mean Std Devition Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) Sponsored by government 4 No idea till now 8 Was not allowed to ask by the Chennai hospital authority 5 Didn't tell 10 Total 27 Number of patients giving amount 23 11418.14 15417.45 242.55 64680.00 7000.00 Total 50 Out of a total of 50 respondents in Chennai, 23 patients gave some information about the cost of their treatment and stay in the hospital. Out of the 27 patients, who didn't give any information about the cost, 8 patients had no idea about the cost as their treatment was still continuing. In the case of 5 patients, the hospital authority didn't allow them to enquire about the cost part, while 10 patients didn't tell. On an average, 23 patients, who told about the money, spent $ 11418.14. The amount spent ranged from a minimum of $ 242.55 to a maximum of $ 64680.00 (Table 4.30). The study conducted by Reddy among 34 patients from different hospitals in Bangalore, Hyderabad and Chennai, shows that the amount spent by international patients for CESS Monograph - 42 128 their treatment and stay was much less. The minimum cost was $ 300 and maximum $16000. The average cost for treatment and stay was $ 6071 (Reddy, 2013).

Table 4.31: Cost of Entire Trip to India Place Reasons Number Mean Std Devition Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) The attendant had no idea 8 Everything arranged by government 5 Was not allowed to ask by hospital Chennai authority 5 Didn't tell 12 Insurance 1 Total 31 Number of patients giving amount 19 9855.99 10720.63 900.00 40000.00 7000.00 Total 50 Of the total 50 international patients, only 19 were willing to speak about the cost of their entire trip to India. There were 31 patients who did not give any information out of which 12 did not want to reveal the amount. In the case of 8 patients the attendant/ patient had no idea about the amount. For 5 patients, everything had been arranged by their government, so they did not have any idea, while 5 patients were not allowed by the hospital authority to speak about the amount. On an average, 19 patients, who gave some information, had spent $ 9855.99 for their trip to India. The amount of money spent by the patients ranged from a minimum of $ 900 to a maximum of $ 40000 (Table 4.31). 4.4.5c: Tourism Medical Tourism combines health care with tourism. Medical tourists look for countries with exotic locales for their treatment where they can also visit a few places along with their medical care. The table 4.32 shows that most of the international patients were not much interested in visiting other places after treatment. Out of a total of 50 patients, 38 (76%) had no Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 129 plans to visit other places while being in India and 24% were interested in visiting other places in India (Table 4.32).

Table 4.32: Planning to do Any Tourism While being in India Sl.No. Any plan of tourism Percentage 1. Yes 12 24% 2. No 38 76% Total 50 100%

Among the four hospitals visited, Sri Ramachandra medical Centre has tie-up with travel agencies to facilitate foreign patients. A study conducted by Pougajendy & Senapathi with respect to various hospitals in Chennai shows that, 76.67% of the respondents were interested in visiting places, while 23.33% were not. The study also infers that 43.33% of the hospitals arranged for visiting places, 36.67% provided guidance and 13.33% made travel arrangements (Pougajendy & R.Senapathi, 2012). For a majority of the international patients, travelling was not an important aspect of medical tourism. The studies reviewed also reveal that, medical tourists might be visiting places after their treatment was over, subject to their health permitting. A few were of the opinion that though they wanted to visit few places, it was not possible as they had their work and families to go back to as soon as possible (Reddy, 2013).

Table 4.33: If yes, which Place you would like to Visit S.No Places Number 1. Beaches, Cathedral, Nearby Places 4 2. Delhi, Agra, Mumbai 1 3. Mumbai 1 4. Taj Mahal, Mumbai 3 5. 2 6. Not planned about the place 1 Total 12 CESS Monograph - 42 130

On enquiring about the places they would like to visit, 4 wanted to see beaches, cathedral and nearby places, 3 had not planned anything, 2 wanted to go to Pondicherry and 1 each wanted to visit Mumbai, Agra and Delhi (Table 4.33). 4.4.6: Availability of Translators/interpreters This segment deals with whether international patients have any language problem in India and whether hospitals provide interpreters. International patients coming from different countries may find communication with others a major problem in India. This necessitates the need for interpreters to be appointed by hospitals. Chennai being one of the preferred choices of international patients, it has opened job opportunities for many who can communicate the needs of international patients to doctors and vice versa.

Table 4.34: Problem with Language Sl.No. Problem with language Percentage 1. Yes 18 36% 2. No 32 64% Total 50 100% Most of the patients coming from Arab countries (64%) had a problem with language, while 36% did not have any problem who could speak in English (Table 4.34).

Table 4.35: Whether the Hospital Provides Interpreters for those with language problem Sl.No. Availability of interpreter/s Percentage 1. Yes 18 100% 2. No 0 Total 18 100% All the 18 patients faced with language problem said that the hospital had provided interpreter/s (Table 4.35). As evident from the data as also the observation tool, all the hospitals visited were providing interpreters for the international patients. However, in most of the hospitals, there was only one interpreter, so it was difficult to cater to all the patients at a time. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 131

4.4.7: Quality of Care This segment deals with the perceptions of the international patients regarding the quality of care provided at the hospital and the satisfaction level of the patients. Patient satisfaction is an important dimension of healthcare/treatment, though it is not always the primary indicator in respect of some treatments.

Table 4.36: Problems, if any, during Admission at the Hospital Sl.No. Problems during admission Percentage 1. Yes 0 2. No 49 98% 3. Waiting for a long time 1 2% Total 50 100% A majority of the patients (98%) responded that they had not faced any problem during admission, while only 1 (2%) had to wait for a long time for admission (Table 4. 36). The foreign patients are immediately taken care of by the staff, so that there is no problem during admission at the hospital. The international wing at Sri Ramachandra Medical Centre has 36 beds, 15 workers and 5staff.

Table 4.37: Whether the Staff was Courteous, Polite, Friendly and Helpful Sl.No. Whether staff friendly or not Percentage 1. Yes 50 100% 2. No 0 Total 50 100%

All the international patients in Chennai were of the opinion that the staff in the hospital was courteous, polite, friendly and helpful (Table 4.37). Among the hospitals visited, Fortis Malar Hospital and Sri Ramachandra Medical Centre have an exclusive wing for medical tourists with a team of staff specially trained in handling international patients. CESS Monograph - 42 132

Table 4.38: Procedures suggested by the Doctor/s Sl.No. Procedures Percentage 1. X-ray 32 64% 2. Specific diagnostic techniques 10 20% 3. Chemotherapy 1 2% 4. Routine Blood Test 30 60% 5. MRI 3 6% 6. C.T.Scan 15 30% 7. PET Scan 4 8% 8. ECG, Echo 7 14% 9. Dialysis 11 22% Total 113 226% Note: Due to Multiple answers, the aggregate percentage may exceed 100. The international patients had been advised to undergo various procedures. Out of the 50 patients, 32 (64%) had undergone X-ray, 30 (60%) had been advised to go for a routine blood test, while 15 (30%) patients had undergone C.T.Scan and 11 (22%) had undergone dialysis (Table 4.38).

Table 4.39: Stages of Treatment Sl.No. Stages Percentages 1. Treatment is over 9 18% 2. Still continuing with treatment 36 72% 3. Regular checkup after treatment 4 8% 4. Don't know 1 2% Total 50 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 133

A majority of the patients (72 %) were still continuing with the treatment, while for 9 (18%), the treatment was over, 4 (8%) patients came for regular checkups after treatment and 1 patient had no idea about the stage of treatment (Table 4.39).

Table 4.40: Whether Satisfied with the Surgical Procedure Sl.No. Satisfied with surgical procedure Percentage 1. Yes 18 36% 2. No 3 6% 3. No operation needed 9 18% 4. Not yet operated 20 40% Total 50 100% Most of the patients who had undergone operations were satisfied with the surgical procedure. When asked whether they were satisfied with the surgical procedure, 36% of the patients replied in affirmation, 40% responded that they were yet to be operated upon and for 18% of the patients, no operation was needed (Table 4.40).

Table 4.41: Whether Satisfied with the Doctor/s Sl.No. Satisfied with the doctor/s Percentage 1. Yes 49 98% 2. No 1 2% Total 50 100% A majority of the patients (98%) were satisfied with the doctor/s, while only 1(2%) was not satisfied (Table 4. 41).

Table 4.42: Whether Satisfied with Care Takers of the Hospital Sl.No. Whether Satisfied with care takers Percentage 1. Yes 50 100% 2. No 0 Total 50 100% CESS Monograph - 42 134

All the 50 patients were satisfied with the care-takers of the hospital (Table 4.42). Various studies reviewed also reveal a high satisfaction level among international patients coming to India for treatment. Out of the 34 international patients interviewed during the study in Bangalore, Hyderabad and Chennai, 32 were either satisfied or happy with their decision to travel to India for treatment (Reddy, 2013).

Table 4.43: Whether Hospital Providing Medicines Prescribed by Doctor/s Sl.No. Hospital providing medicine Percentage 1. Yes 49 98% 2. No 0 3. No medicine has been prescribed 1 2% Total 50 100%

In almost all the cases (98%), medicines prescribed by the doctor/s were provided by the hospital and in the case of 1 (2%) patient, no medicine had been prescribed by the doctor (Table 4.43).

Table 4.44: Whether Information Regarding Recovery given to Family by Doctor/Nurse Sl.No. Information regarding recovery Percentage 1. Yes 34 68% 2. No 8 16% 3. Will tell after surgery 8 16% Total 50 100%

When asked whether information regarding recovery had been given to the family members by the doctor/nurse, 34 (68%) patients answered in affirmation, while the families of 8 (16%)patients had not been given any information and 8 (16%) patients stated that they would be given some information only after the surgery and that they were still continuing with the treatment (Table 4.44). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 135

Table 4.45: Whether the Nurse/Doctor Explained the Purpose of Medicine/s to be Taken at Home Sl.No. Purpose of medicine explained Percentage 1. Yes 21 42% 2. No 7 14% 3. Not yet 22 44% Total 50 100% When asked whether the nurse/doctor had explained to them the purpose of medicines to be taken at home, 44% patients said "not yet" as the treatment was going on and 14% patients said "no", while 42% patients had been explained about the medicines to be taken at home (Table 4.45).

Table 4.46: Whether Satisfied with Hygiene and Cleanliness at the Hospital Sl.No. Whether Satisfied with hygiene/cleanliness Percentage 1. Yes 49 98% 2. No 1 2% Total 50 100% Out of the 50 international patients, 98% were satisfied with hygiene and cleanliness at the hospital, while 2% were not satisfied (Table 4.46). As the above data shows, foreign patients are satisfied with hygiene and cleanliness at the hospital which is also evident from the observation tool. The cleaning staff is at work throughout the day.

Table 4.47: Whether the Hospital Providing Accommodation for Attendant/s Sl.No. Accommodation for attendant/s Percentage 1. Yes 44 88% 2. No 6 12% Total 50 100% CESS Monograph - 42 136

Out of a total of 50 international patients in Chennai, for 44 (88%) patients, the hospital had provided accommodation for the attendant/s and the remaining 6 (12%) patients had to arrange for the accommodation of their attendant/s (Table 4.47). Table 4.48: If no, How did They Arrange Accommodation for Attendant/s Sl.No. Alternate arrangement of accommodation Percentage 1. Hospital arranged the accommodation 1 16.7% 2. Personal arrangement in an A star hotel 4 66.6% 3. Other(specify)- Personally looked for a house near the hospital 1 16.7% Total 6 100% Among the 6 patients who had to arrange for the accommodation of their attendant/s by their own, 4 (66.6%) had made personal arrangement in an 'A' star hotel, 1 patient looked for a house near the hospital, while in the case of 1 patient, the hospital had arranged for the accommodation outside of the hospital (Table 4.48).

Table 4.49: Quality of Food served in the Hospital Sl.No. Quality of food Percentage 1. Excellent 9 18% 2. Decent 25 50% 3. Dissatisfactory 3 6% 4. Not had food in the hospital 2 4% 5. Different, a little spicy but ok 7 14% 6. Good 4 8% Total 50 100% Most of the international patients found the food served in the hospital/s satisfactory. Out of the 50 international patients interviewed, 7 (14%) patients found the food provided in the hospital "different, little spicy but ok". For 25 (50%) patients, the food Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 137 served was decent, for 4 (8%) patients, the food was good, while for 9 (18%) patients, it was excellent. Only 3 (6%) patients found the food dissatisfactory (Table 4.49). Special diet is available for foreign patients in all the hospitals visited with the patients being satisfied with the food provided in the hospital/s. However, an earlier study conducted in respect of 5 major hospitals in Bangalore shows that most of the patients were not satisfied with the food provided by the hospital/s. Among all the patients, 76% of the international patients were not satisfied with the food provided by the hospital/s, 18% were satisfied and for 6% of the patients, food was excellent (Anvekar, 2012).

Table 4.50: Whether Patients had Received any Prior Information about their Discharge Sl.No. Information about discharge Percentage 1. Yes 16 32% 2. No 7 14% 3. Still continuing with treatment 26 52% 4. Not yet discharged 1 2% Total 50 100% When enquired whether they had received any information about their discharge, 16 (32%) patients replied in affirmation, while 7 (14%) said 'no' and 26 (52%) were still continuing with the treatment, so did not have any information, while 1 (2%) was yet to be discharged (Table 4.50).

Table 4.51: Whether the Doctor had Prescribed Any Medicine Post their Treatment Sl.No. Whether medicine prescribed by doctor Percentage 1. Yes 12 24% 2. No 3 6% 3. Not yet over 35 70% Total 50 100% CESS Monograph - 42 138

Out of 50 patients, for 35 (70%) patients, the treatment was not yet over. The doctor/ s had prescribed medicines for 12 (24%) patients, while in the case of 3 (6%) patients, no medicines had been prescribed (Table 4.51).

Table 4.52: Availability of medicines in their Country for those Medicines had been prescribed Sl.No. Availability of medicine in their country Percentage 1. Only in a few places 3 25% 2. Everywhere 6 50% 3. Haven't checked 2 16.7% 4. Hospital provides for 1 month 1 8.3% Total 12 100% When asked where in their country were the medicines available, 6 (50%) patients said "everywhere", 3(25%) patients said only in a few places, while 1 (8.3%) patient responded that the hospital provided medicine for 1 month and 2 (16.7%) patients had not checked whether medicines were available or not (Table 4.52).

Table 4.53: Whether the Alternate of the Medicine Prescribed Available in Your Country Sl.No. Alternate medicine available Percentage 1. Yes 4 22.2% 2. Not Available 4 22.2% 3. Will take from India 5 27.8% 4. Did not know 5 27.8% Total 18 100% When asked whether alternate medicines were available in their country, 5 (27.8%) said that they would take medicines from India and 27.8% were not aware, while 22.2% each said "yes" and "not available" (Table 4.53). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 139

Table 4.54: Will You Come Here for Follow up Treatment Sl.No. Whether coming back for follow up treatment Percentage 1. Yes 46 92% 2. No 2 4% 3. Might be coming 1 2% 4. Yes, if within visa period 1 2% Total 50 100%

Out of the 50 international patients interviewed, an overwhelming 46 (92%) patients responded that they would come back for follow up treatment, while 2 (4%) said 'no' and 1 (2%) patient stated that he would come back if it was possible within the visa period (Table 4.54).

Table 4.55: Would You Come here in Future, if You Need any Treatment Sl.No. Coming here in the future Percentage 1. Yes 47 94% 2. No 1 2% 3. Can't say 2 4% Total 50 100%

Out of a total of 50 international patients, 47 (94%) said that they would come back here in future, if required, for treatment. Only 1 (2%) patient said he won't come back while 2(4%) patients said they were not sure (Table 4.55).

Out of 50 international patients, 48 (96%) said that they would inform others in their country about this hospital, while only 1 patient said that he would not recommend the hospital to others and 1 patient was not sure (Table 4.56). CESS Monograph - 42 140

Table 4.56: Would You Like to Suggest to Others this Hospital in Your Country Sl.No. Would suggest to others Percentage 1. Yes 48 96% 2. No 1 2% 3. Not sure 1 2% Total 50 100% The number of patients coming to Sri Ramachandra Medical Centre has increased over the years, as revealed by the hospital personnel. Similar results have been found in the other studies reviewed. According to a study carried out by Reddy among 34 patients in Bangalore, Hyderabad and Chennai, 32 patients would recommend medical tourism to their friends and family members, based on their experience in India (Reddy, 2013). 4.5: Ethical Issues Ethical dilemmas are associated with medical tourism despite the benefits of lower costs and reduced waiting periods for medical tourists. Medical tourists may face problems with regard to care and the quality of medical treatment. Moreover, this system can result in a substantial utilisation of medical resources for catering to foreign patients, thus leaving very little for the locally less privileged patients. The increased competition to attract foreign patients may lead to increased unethical practices, especially with regard to organ transplantation and experiments on human beings as guinea pigs. This may also prompt patients seek transplantation in countries where illegal and unauthorized donors are easily available to sell their body organs as part of combating poverty. The organs are sold and, at times, taken by force, from the poor and underprivileged. Even in the presence of a national regulatory act, illegal organ transplantations are on the rise in India. Surrogacy is another such issue. Organ transplantation, particularly kidney transplantation is on the rise in Tamil Nadu. The Tsunami victims in Chennai are being targeted to carry on illegal kidney transplantations among foreigners. In 2013, the police busted a kidney racket in Dharmapuri region. The city of Chennai earned disrepute in the eighties and early nineties when hundreds of poor people sold off their kidneys illegally. Discussed below are some cases of illegal kidney transplantation in Tamil Nadu, based on newspaper reports. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 141

An investigation into kidney transplantation in Tamil Nadu which is targeting Tsunami victims of Chennai reveals that a large number of kidneys donated are being illegally transplanted onto foreigners. There is a large network of kidney brokers catering to several hospitals in Chennai, Madurai, Tiruchi, Tirunelveli and Coimbatore. These hospitals have been getting a large number of patients from the Gulf, Sri Lanka and the Far East, seeking organ transplants. The patients consider the transplants safe and affordable here than in their country. The hospitals charge Rs 5 lakhs per kidney transplant from foreigners as against Rs 2 lakh from Indian patients. However, the donors, who are poor tsunami victims, are given only Rs 40,000.The foreigners come on tourist visas to get the transplants done. According to the local police, there could be large-scale falsification of documents or no documentation at all in some cases (Ram, 2007). On June 10, 2013, the police in Dharmapuri region in Tamil Nadu unearthed a kidney racket with the arrest of a broker. The racket had spread across various districts including Dharmapuri, Krishnagiri, Salem, Namakkal and Coimbatore. A nephrologist attached to a Salem-based hospital was also arrested for his connections with the illegal transplant racket (Arivanantham, 2013). In the eighties and early nineties, a roaring illegal racket, where hundreds of poor people had their kidneys sold off illegally, brought international disrepute to the city of Chennai. Also, the involvement of private and corporate hospitals has raised some ethical questions. In their urge to undertake transplants, sometimes, doctors at these hospitals overlook the quality of cadaver kidneys which might lead to possible failures. These hospitals charge several lakhs of rupees from patients for surgery, but do not advise the patients and their family on the possibilities of transplant failures. In 2012, one of the hospitals had transplanted a kidney from a person who was brain-dead because of dengue fever. The patient, in this case, had not been informed about the condition of the donor. A few years ago, there was another case, in which the kidney belonged to a person who had died of a snake-bite. Although organs from snake-bite related brain-deaths are admissible, ethically the patient needs to be consulted and informed (Kumar, 2012). Surrogacy is another issue. The surrogacy market in Chennai is on the rise, but many of the women who come from small towns and villages often feel cheated. The inability to have children can be extremely heartbreaking and devastating to their future plans. As the number of surrogate mothers has grown with the clinics, childless couples from different parts of the country and abroad come to Chennai. But there is virtually no law to protect the rights of surrogate mothers during or after pregnancy. Most of these women are brought to the city clinics from small towns and villages by brokers who CESS Monograph - 42 142 take away a big chunk of the promised money. With no registration or government monitoring, women have nowhere to go once they have delivered the child (Ramkumar, 2013). Discussed below are two cases of surrogacy, based on newspaper reports. Recently, the case of a Japanese couple travelling to India for hiring a surrogate mother has highlighted the need for strict regulations in respect of surrogacy. A Japanese couple Yamada came to India to hire a surrogate mother. A married woman was arranged to be the surrogate and an embryo made from Yamada sperm and an egg harvested from an anonymous Indian woman were transferred into the surrogate's womb. In 2008, the Japanese couple divorced and a month later, Baby Manji was born. Although Yamada wanted to keep the child, his ex wife did not. The surrogacy contract did not cover this type of situation. The baby had three mothers-the intended mother who had contracted for surrogacy, the egg donor and the gestational mother, yet none was legally responsible for the baby. The Japanese civil code recognizes the woman who gives birth as the sole mother and does not recognize either the surrogate or the surrogate baby, and baby Manji was not entitled to a Japanese passport. After a long legal process, the Anand municipality issued a birth certificate to Manji Yamada stating only her father's name. The official processing of the application for a travel document to Japan could finally proceed. Baby Manji was five months old when the Japanese embassy issued a visa on humanitarian grounds (Lavania, 2014). In 2011, around 2000 couples from abroad had used the services of Indian surrogate mothers. A single mother of two from Chennai agreed to become a surrogate mother in order to earn some quick money. She delivered a healthy baby, but got only half the money promised to her as the remaining half was taken away by middleman. Further, she had to bear additional expenses when she developed some after-delivery complications a few weeks after the delivery. Surrogacy is cheap and unlike many other countries, is legal in India. However, after the baby is born, the mother is left with no one to take care of her health problems which she might develop due to pregnancy. A group of Chennai-based social workers, who have set up the Global Surrogate Mothers Advancing Rights Trust (G-MART), aims at safeguarding the rights of poor women who are prepared to become surrogate mothers in the region (Rahman, 2014). As a medical concept, surrogacy is a good option for infertile couples who cannot have babies through any other means. However, in practice, surrogacy has become a commercial transaction. The physical and emotional trauma that a paid surrogate undergoes and the health risk that a surrogate baby faces, as the baby is denied of immunological and psychological health and the benefits of breast feeding, are of no concern for medical tourists from abroad (Sharma, 2013). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 143

4.6: Summary The city of Chennai has been termed as the health capital of India. The various multi and super specialty hospitals in the city bring in an estimated 150 international patients every day. It is supposed to be the epicenter of India's medical tourism industry with its cheap healthcare, world class medical technology and English speaking doctors. According to the TOI April, 2013, Chennai attracts about 40% of the country's medical tourists and more than 6 lakh tourists visit the city every year. This study among 50 international patients in various hospitals in Chennai tries to find out the background characteristics of the patients, the reasons to choose India for their treatment, treatment expenses, visa issues, tourism related issues and the satisfaction level of patients. The background characteristics of the international patients reveal that more male patients than females come for treatment who are mostly married and in the category of 20-50 years of age. The educational qualification shows that nearly 38% are graduates out of which 84.2% are males. Nearly 44% are self-employed. In Chennai, most of the patients are from the Middle East countries (48%) followed by 46% from Africa. A few (6%) are from South Asian countries. The patients come for various types of treatment. There were 18% of the patients who had come for cardiac treatment followed by 16% for neurological problems. Most of the patients chose to come to India for treatment because of the presence of specialized doctors here (98%) followed by 48% of the patients choosing low cost as one of the reasons for coming to India. More than half of the patients had come to know of the hospital from their friends and relatives, while 46% of the patients had been referred by the doctors at their place. Most of them had contacted the hospital either online or over the phone. Regarding the visa issue, 94% did not have any problem in getting visa and 49 patients found the staff at the Indian embassy friendly and helpful. One patient did not have to deal with the embassy as he had overseas citizenship of India (OCI). A majority of the patients had visa for 6 months, while a majority didn't have any health insurance (92%). The expenses of treatment ranged from a minimum of 242.55 dollars to a maximum of 64680.00 dollars. The very concept of medical tourism combines health care and tourism. However, this study shows that, only 24% of the patients were willing to visit different places after their treatment was over, while 76% wanted to go back home immediately after the treatment. CESS Monograph - 42 144

Most of the international patients in Chennai were from Middle East countries (48%) who were not very fluent in English. So nearly 64% had a problem with language. However, all the patients faced with the language problem were provided interpreter/s by the hospitals. The international patients were, overall, satisfied with the experience they have had at the hospital. They did not have any problem during admission and found the staff in the hospital/s very courteous, polite, friendly and helpful. They were all satisfied with the surgical procedures and the doctor/s. However, 40% of the patients were yet to be operated upon. Almost 98% of the patients were satisfied with cleanliness and hygiene at the hospitals, while only one patient was not satisfied. Nearly 50% of the patients found the food served in the hospital decent. Overall, the patients were satisfied with their experience at the hospitals. They were (92%) willing to come to the same hospitals for follow-up treatment and for treatment, if required, in the future. And 48% of the patients said that they would definitely recommend the hospitals to others in their country. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 145

5. Medical Tourism in Mumbai

5.1 Introduction Maharashtra is a state in the western region of India and is the nation's and also the world's second-most populous sub-national entity. It has over 110 million inhabitants and its capital, Mumbai, has a population of approximately 18.4 million. Mumbai is also the financial capital of the nation and the headquarters of all major banks, financial institutions and insurance companies in the country (Map 5.1). Maharashtra's business opportunities along with its potential to offer a higher standard of living attract migrants from all over India. Maharashtra is one of the wealthiest and the most developed states in India, contributing 25 percent of the country's industrial output and 23.2 percent of its GDP (2010-11) (Rediff, 2012). Map 5.1: Maharastra State in India CESS Monograph - 42 146

5.1.1 A Demographic Profile of Maharashtra According to 2011 National Census, Maharashtra is the second populous state of India. The total population of Maharashtra stands at 112,374,333 of which males and females constitute 58,243,056 and 54,131,277 respectively. The state has a density of 365 per sq Km which is lower than the national average. The sex ratio in Maharashtra is 929 which is below the national average of 940. The literacy rate of the state is 82.34 percent with male literacy at 88.38 percent and female literacy at 69.87 percent (Table 5.1).

Table 5.1: A Demographic Profile of Maharashtra Particulars Maharashtra, 2011 Census Male Female Total Population 58,243,056 54,131,277 1,12,374,333 Density 365 Sex Ratio 929 Literacy rate (%) 88.38 69.87 82.3 Source: Census, 2011 5.1.2 Tourism in Maharashtra Maharashtra attracts many tourists from different states in India as also from other countries. The state is famous for various hill stations, religious places, fashion, beaches etc. The innumerous forts, many basalt rock temples and its diverse and colourful cultures represent the true nature of the state. Some of the famous places are Shirdi, Elephanta caves, Ajantha and Ellora caves, Nariman Point, Gate way of India, Bollywood, ISCKON Temple, Marine Drive, Powai Lake, Haji Ali Mosque, Essel World, Hotel Taj, Magarpatta, etc. However, it is Bollywood that gives Maharashtra an edge over other states of India. Maharashtra is a complete tourist destination in itself and a delight for those fond of travelling. With all its attractions, Maharashtra exudes a mesmerizing aura which is hard to ignore. Maharashtra is the most visited state in India by foreign tourists, with more than 3 million foreign tourist arrivals annually (Table 5.2&Figure 5.1).

Table 5.2: Foreign Tourist Arrivals in Maharashtra, July 2009-March 2014 Year No. of foreign tourists July2009-June2010 21,26,933 Apr2011-Mar2012 20,44,796 Apr2013-Mar2014 31,23,459

Source: Department of Tourism, Govt. of India, 2014 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 147

Figure 5.1: Foreign Tourist Arrivals in Maharashtra, July 2009-March 2014

5.1.3 Health Care in Maharashtra Maharashtra has been at the forefront as far as healthcare development in India is concerned. It has been one of the first states to have achieved the norms mandated for primary health centres, sub-centres and rural hospitals, under the Minimum Needs Programme (MNP). It is also among the first states to have decentralized primary health care administration through Zilla Parishads as early as in 1961. The state also has the largest private health sector in India whose reach is quite extensive (GoM, 2016). In 2011, the health care system in Maharashtra consisted of 363 rural government hospitals, 23 district hospitals (with 7,561 beds), 4 general hospitals (with 714 beds) mostly under the Maharashtra Ministry of Health and Family Welfare, and 380 private medical establishments providing the state with more than 30,000 hospital beds. It is the first state in India to have had nine women's hospitals serving 1,365 beds (GoM, 2014). Maharashtra, being the commercial and financial state of India, is now coming up as the most suitable destination for Medical Tourism within the country. The main reason for this is Maharashtra's geographic location which is easily accessible and well connected to all the parts of not only India, but also the rest of the world. Recently, with an objective of "To Deliver 'value for money' Health Care with a Human Touch", FICCI and the government of Maharashtra have joined hands to provide the best available CESS Monograph - 42 148 services to patients coming from other parts of the country as also from the world at reasonable prices.(Kaur, G, Vaidya, & Bhargava, 2007). 5.2 Mumbai Mumbai is the capital city of Maharashtra State, India. It is the most populous city in India, and the eighth most populous city in the world (Map 5.2). Map 5.2: Mumbai in Maharashtra

5.2.1 A Demographic Profile of Mumbai As per 2011 Census, the population of Mumbai stands at 12,478,447 of which males and females constitute 6,736,815 and 5,741,632, respectively. The average literacy rate of Mumbai city is 90.28 percent of which male literacy is 93.32 percent and female literacy is 86.70 percent. It has a sex ratio of 852 per 1000 males (Table 5.3). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 149

Table 5.3:A Demographic Profile of Mumbai Particulars Sex Male Female Total Population 6,736,815 5,741,632 12,478,447 Sex Ratio 852 Literacy rate (%) 93.32 86.70 90.28 Source: Census of India, 2011

About 49 percent of the population resides in slums, characterized as it has been by a shortage of living space, water supply and sanitation facilities. The health and sanitation conditions across slums are poor with the proportion of people falling sick being very high. It is necessary to provide adequate, timely and cost effective health care services to the ailing population (Census, 2011).

5.2.2 Tourism in Mumbai Mumbai is undoubtedly the commercial capital of India in addition to being one of the predominant port cities in the country. It is the financial as well as the entertainment capital of India. Mumbai's nature as the most eclectic and cosmopolitan Indian city is symbolized by Bollywood within the city, as the centre of globally-influential Hindi film and TV industries. Mumbai houses some of the country's holiest shrines with the Siddhivinayak Temple dedicated to Lord Ganesha and Haji Ali Mosque being two of these shrines. Mumbai boasts of many tourist spots like the Gateway of India, Prince of Wales Museum, Mahalaxmi Temple, Chowpatty, etc., to name a few.Table 5.4 and Figure 5.2 show the details of foreign tourists in Mumbai.

Table 5.4: Foreign Tourist Arrivals in Mumbai from July 2009 to March 2014 Year No. of foreign tourists July2009-June2010 16,72,446 Apr2011-Mar2012 17,05,016 Apr2013-Mar2014 20,45,597 Ministry of Tourism, Govt. of India, 2010, 2012, 2014 CESS Monograph - 42 150

Figure 5.2: Foreign Tourist Arrival in Mumbai, July 2009- March 2014

5.2.3 Health care in Mumbai Mumbai city houses hospitals and dispensaries run by Municipal Corporation of Greater Mumbai (MCGM), state government and private trusts. MCGM, the largest Municipal Corporation in India, is the major provider of public health care services in Mumbai with a network of 4 teaching hospitals, 5 specialized hospitals, 16 peripheral hospitals, 28 municipal maternity homes and 14 maternity wards attached to municipal hospitals with more than 17000 employees working in these hospitals.This apart, there are 168 municipal dispensaries, 176 health posts to provide outpatient care services (Table 5. 5). In addition, the state government runs one medical college hospital, 3 general hospitals and 2 health units, with a total of 2871 beds (Arya, 2012).

Table 5.5: Healthcare in Mumbai as of 2010-2011 Sl No. Healthcare in Mumbai Numbers 1. Municipal maternity Homes 28 2. Peripheral Hospitals 16 3. Specialized Hospitals 5 4. Municipal Dispensaries 168 5. Health Posts 176 Source: (Arya, 2012) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 151

5.2.4 Medical Tourism in Mumbai India has emerged as one of the most prominent destinations for medical tourists coming from the world over. Quite a few Indian cities have also emerged as medical tourism hotspots for foreign patients such as Delhi, Bangalore, Chennai, etc., but one city that has really been at the forefront is Mumbai, a hot favorite with medical tourists. Mumbai has become the main centre for medical tourism with 282 private general hospitals, 14 multi-specialty hospitals and three super specialty hospitals. There are special hospitals in Mumbai as well - five for cancer care and 4 heart institutes. Doctors and hospitals are on par with international standards and yet are very cost-effective as compared to their international counterparts. (Arya, 2012). Advantages associated with Medical Tourism in Mumbai: ● Mumbai has a number of excellent hospitals and specialty centers. ● Mumbai's geographic location makes it a very accessible hub for people coming from overseas. It has one of the busiest international airports in the world. ● The hospitals have tie-ups with reputed medical schools in the US and UK, and access to international expertise and technology. ● Cost of medical treatments in Mumbai is 60-80 percent low in comparison to the developed nations. ● The hospitals have excellent facilities and the areas of expertise include Cardiology, Cardiothoracic Surgery, Gastroenterology, Neurosurgery, Plastic Surgery, Obesity Surgery, Oncology and other fields of Medicine. ● Hospitals are also teaming up with hotels and travel agencies with respect to providing treatment and tourism packages to interested patients and their families. ● Another edge that the city has is of the vastly English speaking nursing staff. The nursing staff is reputedly well trained, besides being good caretakers as well (Arya, 2012). 5.2.4a Future Prospects of Medical Tourism in Mumbai The city offers almost all types of treatment to their clients. The doctors use the very latest technology and equipments for carrying out operations. Organ transplants are quite successfully done in hospitals. Mumbai has seen a rush of health care providers setting up super specialty hospitals with facilities like air ambulance and shopping plazas. Hospitals seek recognition from CESS Monograph - 42 152 insurance companies abroad, so that the patients are able to avail themselves of health insurance, as they would in their own country. Hospitals are also focused on receiving accreditation from the Joint Commission International (JCI), USA, to ensure global standards in patient care, safety and quality of service. 5.2.5 Accreditation of Hospitals The process of accreditation is a voluntary process depending on the hospital which wants to be accredited. It is considered an important benchmark of quality and safety for insurers and patients for any healthcare organization. Accreditation follows a rigorous process stretching over a period of six months, during which, almost 513 measurable elements related to the care of patients, management of the hospital, training and education of staff and the continuum of care are tracked and optimised. It involves training, audits (both internal and external) and process optimisation.

Table 5.6: A List of Hospitals in Mumbai SL. Name of the Accreditation No. of No. of No. of Medical No. Hospital of the hospital beds doctors paramedical tourism staff 1. Asian Heart Institute JCI, ISO, NIAHO 280 150 75 yes 2. Cumballa Hill Hospital and Heart Institute 50 100 40 yes 3. P D Hinduja National NABL, ISO, 342 190 200 yes Hospital & Medical NABH, CAP Research Centre, 4. Nanavati Super ISO 352 200 80 yes Specialty Hospital 5. Saifee Hospital NABL, ISO 250 yes 6. Jaslok Hospital NABH 365 300 352 yes 7. Tata Memorial Hospital JCI yes 8. Shroff Eye Hospital JCI, ISO yes 9. Lilavati Hospital & Researh Centre yes 10. Seven Hills Hospital yes 11. Apollo Hospital yes 12. Global Hospital NABH, NABL, 450 260 156 yes NALAL 13. Kohinoor Hospital NABH 175 200 350 yes 14. S.L.Raheja NABH 140 175 35 yes Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 153

Kokilaben Hospital is the only Hospital in Western India to have been awarded with an internationally recognized CAP accreditation (College of American Pathologists) within four years of its establishment for both Medical Laboratory and Blood Bank. The CAP Laboratory Accreditation Program is an internationally recognised program based on rigorous accreditation standards, covering a complete array of disciplines and testing procedures through which it helps to achieve a consistently high level of service throughout the institution and the healthcare system. Table 5.6 shows a list of major hospitals in Mumbai with the number of beds, doctors and paramedical staff and having facilities for medical tourists.

Table 5.7: Hospitals Visited for the Study Sl No Name of the hospital No of patients Observations 1. Asian Heart Institute 6 One help desk and an admission counter available in the main hall, where the persons are well versed in English, Hindi and Marathi. They have to wait for some time before consulting the doctor. The hospital has a drug store, blood bank and cafeteria. Cleanliness and hygiene in the hospital are well maintained. 2. Camballa Hill Hospital 1 There is an admission counter, but and Heart Institute there is no separate help desk. The hospital premise is very clean. The staff is very polite towards patients waiting at the waiting hall. Drug store and cafeteria are also available inside the hospital premises. 3. P.D. Hinduja National 3 The premises of the hospital are well Hospital and Medical maintained. The patients have to wait in the Research Centre. normal waiting room which is available in every floor. 4. Dr. Balabhai Nanavati 1 There is a waiting room in which snacks and Superspeciality Hospital drinking water for patients are provided. Cleanliness and hygiene of the hospital are well maintained with both wet and dry dust bins. Blood bank, drug store and cafeteria are available inside the hospital premises. There is a very strict security check at the entrance of the hospital. Table-5.7 contd.. CESS Monograph - 42 154 Table-5.7 contd.. 5. Kokilaben Dhirubhai 5 There is a separate help desk for international Ambani Hospital patients. Hygiene and cleanliness are well maintained. There are a drug store and cafeteria in the hospital premises. 6. Global Hospital 13 The hospital is clean and hygienic. Drug store and cafeteria available inside the hospital premises. 7. Jaslok Hospital 8 Waiting room has facilities like TV, Newspapers, magazines and an enough seating arrangement. The hospital has a drug store and cafeteria inside the hospital premises. Cleanliness and hygiene are well maintained. 8. S.L. Raheja Hospital 13 Waiting room is clean with brochures, books and magazines. Hygiene is well maintained; particularly international patients' floor is frequently cleaned. Drug store and cafeteria are there in the hospital premises. Total 50

5.3 Hospitals Visited for the Study 1. Asian Heart Institute Asian Heart Institute (AHI) was set up with an aim to provide a world-class cardiac care in India. AHI was set up as a holistic approach to heart care based on Ethics, Quality Care with the best of professionals and competitive prices. It prides itself on quality in terms of design, patient care, medical, paramedical, general Staff and infrastructure facilities. The hospital has a patient-centric design with a stress on safety and comfort of patients. All patient areas have been designed to minimize the risk of infection (Table 5.7). Accreditation: JCI, ISO, NIAHO Facilities: Number of doctors- 150 Number of nurses-230 Number of paramedical staff- 75 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 155

Number of departments- 7 Number of specializations- 5 Number of beds- 280 Number of inpatients- 200/day Number of outpatients-250/day Separate wing for International Patients: There is no separate help desk for international patients. Once the patients find themselves inside the hospital they are taken care of by a dedicated staff. Countries of International patients: The international patients are from different countries. Average number of medical tourists in a year: Currently, the hospital receives nearly 6 international patients per month. Age of International patients: International patients of all age groups come to the hospital for treatment. Special services provided by medical tourism division: Special services offered by the hospital to the international patients include online counselling, electronic transfer of medical records, tie-ups with insurance providers, interpreters, special diet and accommodation for the companion/s of medical tourists. 2. Camballa Hill Hospital & Heart Institute With an impeccable record of 30 years of dedicated services to the community, Cumballa Hill Hospital has always strived to keep abreast of the latest developments in the world of medicine. Its goal is to transform itself into a super specialty center with an excellent quality health care with a human touch. The hospital receives around 50 international patients per day mostly from Africa and UAE. Facilities: Number of doctors- 100 Number of nurses-200 Number of paramedical staff- 40 Number of departments- 6 Number of specializations- 3 Number of beds- 50 Number of inpatients- 40/day Number of outpatients- 120/day CESS Monograph - 42 156

Separate wing for International Patients: There is no separate help desk for international patients. Countries of International patients: International patients are usually from Africa and UAE. Average Number of International patients in a year: The hospital receives around 50 international patients in a year. The patients belong to all age groups. Special services provided by medical tourism division: Online counseling, arranging for medical tourism facilitator/s, interpreter/s and special dietary services are some of the special services provided by the hospital to international patients. 3. P.D. Hinduja National Hospital and Medical Research Centre. As an ultra-modern tertiary care hospital in Mumbai, Hinduja Hospital is motivated to lead the pathway to medical excellence with world-class healthcare treatments and services. The hospital's mission is to assimilate the finest in medical and surgical talent and techniques, to bring them closer to the common man. As a tertiary care hospital, the services offered are comprehensive, covering from investigation and diagnosis to therapy, surgery and post-operative care. The hospital covers various specialties like Cardiology, Cardiothoracic Surgery, Neurology, Neurosurgery, Orthopaedics, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Gastro-enterology, Paediatrics, Paediatric Surgery, Paediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynaecology, Pulmonology, Psychiatry, General Medicine and General Surgery. Accredition: NABL, NABH, CAP, ISO Facilities: Number of doctors- 190 Number of nurses-500 Number of paramedical staff- 200 Number of departments- 20 Number of specializations- 16 Number of beds- 342, inclusive of 53 critical care beds Number of inpatients- 250/day Number of outpatients-600/day Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 157

Separate wing for International Patients: No separate help desk for international patients. However, foreign patients are taken to a VIP lounge if the doctor/s is not available, while the domestic patients wait in a waiting room available in every floor. There is a separate trained staff (7 staff and 20 workers) for an easy movement of foreign patients. Countries of International patients: The international patients who come for treatment are usually from USA, Africa and UAE. Average Number of International patients in a year: The hospital receives around 100 patients per year. Special services provided by the medical tourism division: The hospital provides special services to international patients like online counselling, electronic transfer of medical records, arranging for medical tourism facilitator/s, interpreter/s, special dietary services, tie-ups with travel agencies and accommodation for patient/s' companion/s. 4. Dr. Balabhai Nanavati Superspeciality Hospital Mumbai's iconic Dr. Balabhai Nanavati Hospital has been at the forefront of healthcare for 64 years. From being a 50 bed facility in a single building, it has now expanded to 5 buildings housing 360 beds, 55 specialty departments offering servicesin every field of modern medicine and health care. Well-equipped hospital rooms, state-of-the-art departments and technologically advanced systems are all backed by consultants, resident doctors, supported by a large nursing, paramedical and technical staff. Accreditation: ISO Facilities: Number of doctors- 200 Number of nurses-400 Number of paramedical staff- 80 Number of departments- 10 Number of specializations- 4 Number of beds- 352 and 74 critical care beds Number of inpatients- 245/day Number of outpatients-250/day Separate wing for International Patients: There is no separate help desk for international patients. The hospital receives 2-3 international patients per month. CESS Monograph - 42 158

Countries of International patients: International patients are usually from Africa and UAE. Age of International patients: The foreign patients are usually in the age group of 40 and above. Average number of medical tourists in a year: The average number of international patients in a year comes to 10. Special services provided by the medical tourism division: The special services provided by the hospital are online counselling, electronic transfer of medical records, tie-ups with insurance providers, translator/s, special dietary services and accommodation for the companion/s of international patients. 5. Kokilaben Dhirubhai Ambani Hospital Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute is India's newest, most advanced tertiary care facility. As the flagship social initiative of the Reliance Group, it is designed to raise India's global standing as a healthcare destination, with an emphasis on excellence in clinical services, diagnostic facilities and research activities. It represents a confluence of top-notch talent, cutting edge technology, state-of-the-art infrastructure and commitment. Accreditation: NABH, CAP. Facilities: Number of doctors- 200 Number of nurses-1200 Number of paramedical staff- 200 Number of departments- 12 Number of specializations- 42 Number of beds- 750 and 180 critical care beds Number of inpatients- 755/day Number of outpatients-231/day Separate wing for International Patients: The hospital has an exclusive wing for international patients with 60 beds and a staff specially trained in handling international patients. Doctor/s is always available with patients immediately referred to the doctor/s. Countries of international patients: The foreign patients are usually from Africa and Gulf countries. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 159

Average number of international patients: The hospital receives around 200 foreign patients per month. Nearly 2400 foreign patients had come for treatment in the year 2014. Age of International patients: The international patients belong to all age groups i.e., upto the age of 50 years. Special services provided by the medical tourism division: Special services provided by the hospital include online counselling with the doctor/s or the coordinator/s, arranging for visa/passport, interpreter/s, and special diet, tie-ups with travel agencies and accommodation for the companion/s with cooking facilities. 6. Jaslok Hospital Jaslok Hospital was set up in 1973 with a very simple mission to provide the best possible medical care using state-of-the-art technology to every single patient, irrespective of one's social background or financial ability. The hospital is well known for launching the latest technologies in different areas of the medical field. Jaslok hospital, with a positive attitude and perseverance of leadership and the support of the staff, has successfully achieved the quality milestone of NABH accreditation. The hospital celebrated 40 years of service to humanity in 2013. Also, the hospital installed an electronic medical records system (EMR) in the year 2009. Accreditation: NABH Facilities: Number of doctors- 300 Number of nurses-600 Number of paramedical staff- 352 Number of departments- 25 Number of specializations- 41 Number of beds- 365 Number of inpatients- 1500 Number of outpatients-7500 Separate wing for International Patients: There is a separate help desk for international patients. Patients are referred to the doctor/s as soon as they reach the hospital.A special care is given to international patients. Countries of International patients: International patients are usually from Africa, UAE, Bangladesh, Nepal, China, Japan and Pakistan. CESS Monograph - 42 160

Age of International patients: The international patients usually fall within the age group of 30-50. Average number of international patients: The number of international patients increased from 40 in 2013 to 62 in 2014 and the number stood at 26 as of Septmber 2015. Special services provided by the medical tourism division: Special services provided by the hospital include online counselling with the doctor/s or the coordinator/s, arranging for visa/passport, medical tourism facilitator/s, interpreter/s, special diets, tie-ups with travel agencies and accommodation for the companion/s both inside and outside of the hospital. 7. Global Hospital Global Hospital Mumbai is a 450-bed super specialty and multi- organ transplant facility, delivering exceptional healthcare services to patients in India and from across the globe. State-of-the-art technology sets the hospital apart from the rest and helps deliver the most advanced healthcare at affordable prices. The Hospital provides most advanced Endoscopic Surgery Centre, Hepatobiliary and Liver Surgeries, Surgical and Medical Gastroenterology, Nephrology, Urology, Minimal Invasive Surgery, Bariatric Surgery and Robotic Surgery, Neurosciences, Cardiology, Cardiothoracic Surgery, Oncology, Gynecology, Orthopedics and Joint Replacement Surgery, etc. A team of highly qualified physicians is supported by skilled and qualified nursing and paramedical staff and administration team. Accreditation: NABL, NABH, HALAL Facilities: Number of doctors- 260 Number of nurses-300 Number of paramedical staff- 156 Number of departments- 28 Number of specializations- 40 Number of beds- 450 Number of inpatients- 130/day Number of outpatients- 100/day Separate wing for International Patients: No separate help desk for international patients. The international desk coordinator takes care of patients immediately and assists them Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 161 in respect of everything. A special care is taken in terms of language support, food and treatment. The hospital has 40 beds for international patients. Countries of International patients: The international patients are usually from Africa and UAE. Average number of international patients in a year: The hospital received 46 international patients in 2013, 80 in 2014 and 65 as ofSeptember 2015. Age of International patients: The foreign patients are in the age category of 30-50 years. Special services provided by the medical tourism division: Electronic transfer of medical reports, arranging for visa/passport, arranging for medical tourism facilitator/s, tie-ups with insurance providers, interpreters, special diets and accommodation for the companion/s of international patients are some of the special services provided by the hospital. 8. S.L.Raheja Hospital S. L. Raheja Hospital with a 140-bed facility, is a center of excellencein respect of diabetesand oncology. At present, the hospital is professionally managed by Ltd. It provides tertiary care in all the major specialties. A well-known hospital in the city of Mumbai for over 25 years, Raheja hospital strives to treat patients with clinical excellence combined with compassion. Families are encouraged to be part of the healing process so as to ensure the delivery of a high quality safe care that in turn, results in an excellent patient experience. The hospital is focused on preventing diseases through an early diagnosis. By way of organising health check-up camps and awareness programs, it hopes to educate people regarding healthy lifestyles and choices. Accreditation: NABL Facilities: Number of doctors- 175 Number of nurses- 550 Number of paramedical staff- 35 Number of departments- 51 Number of specializations- 40 Number of beds- 140 Number of inpatients- 800-850/month Number of outpatients- 3000/month CESS Monograph - 42 162

Separate wing for International Patients: The hospital has a special arrangement with 25 beds for international patients supported by a specially trained staff. International patients are given a special emphasis on their food, accommodation and medical treatment. Countries of International patients: The international patients are usually from Africa, Bangladesh and Nepal. Age of International patients: The foreign patients are mostly in the age group of 30-50. Average number of international patients in a year: The hospital received around 38 international patients in the year 2014 and 24 as of September 2015. Special services provided by the medical tourism division: Special services provided by the hospital include online counseling with the doctor/s or the coordinator/s, arranging for visa/passport, arranging for medical tourism facilitator/s, tie-ups with insurance providers, interpreter/s, special diets, tie-ups with travel agencies and accommodation for companion/s both inside and outside of the hospital. 5.4 Study of International Patients In this section, an attempt has been made to examine the data collected from international patient with a view to understand the reasons underlying the choice of India by foreign patients for treatment. An attempt has also been made to analyze the medical and travel expenses of international patients. Customer satisfaction is a critical issue in the success of any business system. Most satisfied customers are normally, keen on repurchasing the products provided the product related performance meets their expectations. The analysis also looks into the perceptions and satisfaction level of international patients regarding the quality of care and relationship with the doctor/s and staff in the hospital/s. 5.4.1 Background Characteristics of International Patients This section examines the background characteristics of international patients like gender, age, marital status, literacy, country they come from and their health problems. Table 5.8: Gender Distribution of International Patients Sl.No. Sex Percentage 1. Male 33 66% 2. Female 17 34% Total 50 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 163

The above table shows that mostly male international patients come to hospitals in Mumbai for treatment. Out of the 50 international patients, 33 (66%) were males as against 17 females (34%)(Table 5.8). Most of the studies reviewed also show that more males came to India for treatment than females (Prakash et al, 2011; Anvekar, 2012; Reddy, 2013; Dhodi, Uniyal, & Sharma, 2014; Sujatha & Subhashini, 2015; Gupta et al, 2015). However, other studies show that females were more in numbers than males (Sajjad, 2009; Maheshwari, Animasahun, & Njokanma, 2012). Table 5.9: Distribution of International Patients by Age Group Sl.No. Age Group (in years) Percentage Male Female Total 1. 11-20 1 2 3 33.3% 66.7% 6% 2. 21-30 2 3 5 40% 60% 10% 3. 31-40 2 1 3 66.7% 33.3% 6% 4. 41-50 14 2 16 87.5% 12.5% 32% 5. 51-60 11 6 17 66% 34% 34% 6. 61-70 2 1 3 66.7% 33.3% 6% 7. >70 1 2 3 33.3% 66.7% 6% Total 33 17 50 66% 34% 100% Most of the patients were 50 or more years of age. Out of the 50 international patients, almost 66% were in the age group of 41-60 years, of which 25 (75.8%) were males and 8 (24.2%) females, while there were 6 (12%) patients in the age group of more than 60 years (Table 5.9). As per the data collected from the staff, international patients of all age groups came to the hospitals for treatment. However, medical tourists from Nanavati Hospital were in the age group of 40-50 years. However, an earlier study by Sajjad among 132 foreign patients in Delhi reveals that 43% of the patients were above 60 years of age, 25% were in the age group of 46-60 CESS Monograph - 42 164 years, 15% in the age group of 26-45 years and 19% in the age group of 18-25 years (Sajjad, 2009). Table 5.10: Distribution of International Patients by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 31 8 39 79.5% 20.5% 78% 2. Unmarried 2 4 6 33.3% 66.7% 12% 3. Widow/er 0 5 5 100% 10% Total 33 17 50 66% 34% 100% Most of the international patients coming to Mumbai for treatment are found married. Out of the 50 international patients, 39 (78%) were married, 6 (12 %) unmarried and 5 (10%) widows. Among the married patients, 31(79.5%) were males and 8 (20.5%) females. Among the unmarried patients, 4 (66.7%) were females and 2 (33.3%) males (Table 5.10). Similar findings are also revealed by a study conducted among 132 foreign patients from various hospitals in Delhi. Out of the total number of patients, 73% were married and 25% unmarried (Sajjad, 2009). Table 5.11: Education wise Distribution of International Patients Sl.No. Level of Education Percentage Male Female Total 1. Primary 0 3 3 100% 6% 2. Secondary 5 7 12 41.7% 58.3% 24% 3. Graduate 18 4 22 81.8% 18.2% 44% 4. Post Graduate/MBA 9 3 12 75% 25% 24% 5. MBBS 1 0 1 100% 2% Total 3 3 1 7 5 0 66% 34% 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 165

Most of the patients who had come to Mumbai for treatment were graduates. Out of a total of 50 patients, 22 (44%) were graduates, 12 (24%) Post graduates and 12 (24%) secondary educated. Among the graduates, 18 (81.8%) were males and only 4 (18.2%) females. Among the post graduates, 9 (75%) were males and only 3 (25%) females. All the primary educated patients (6.3%) were females (Table 5.11). Table 5.12: Occupation-wise Distribution of International Patients Sl.No. Occupation Percentage Male Female Total 1. Business 14 2 16 87.5% 12.5% 32% 2. Private job 9 4 13 69.2% 30.8% 26% 3. Government job 5 1 6 83.3% 16.7% 12% 4. Doctor 1 0 1 100% 2% 5. Police 1 0 1 100% 2% 6. Student 2 2 4 50% 50% 8% 7. Not working 1 8 9 11.1% 88.9% 18% Total 33 17 50 66% 34% 100%

The above table shows that a majority of the international patients were into business (32%), followed by 26% of the patients holding some kind of private jobs. Out of 16 (32%) patients, who were doing business, 14 (87.5%) were males and only 2 (12.5%) females. Among those engaged in private jobs, 9 (69.2%) were males and 4 (30.8%) females. Only 9 (18%) were occupation-less with females (88.9%) out numbering males (11.1%) (Table 5.12).

Another study with respect to patients in Delhi also shows that 48.5% were self-employed and 51.5% were unemployed or dependant (Sajjad, 2009). CESS Monograph - 42 166

5.4.2: Background Characteristics of Family Members of International Patients This section examines the demographic details like sex, age, marital status, education and occupation of the family members of international patients.

Table 5.13: Age wise Distribution of Family Members Sl.No. Age Group (in years) Percentage Male Female Total 1. upto-10 5 7 12 41.7% 58.3% 6.9% 2. 11-20 15 16 31 48.4% 51.6% 17.7% 3. 21-30 14 18 32 43.8% 56.2% 18.3% 4. 31-40 15 18 33 45.5% 54.5% 18.9% 5. 41-50 22 13 35 62.9% 37.1% 20% 6. 51-60 15 8 23 65.2% 34.8% 13.1% 7. 61-70 3 3 6 50% 50% 3.4% 8. >70 1 2 3 33.3% 66.7% 1.7% Total 90 85 175 51.4% 48.6% 100%

The above data reveals that 33 (18.9%) family members were in the age category of 31- 40 years, 35 (20%) in the age category of 41-50 years, 31 (17.7%) in the age category of 11-20 years and 32 (18.3%) in the age category of 21-30 years and 23 (13.1%) in the category of 51-60 years. There were 3 (1.8%) members who were above 70 years of age (Table 5.13). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 167

Table 5.14: Distribution of Family Members by Marital Status Sl.No. Marital Status Percentage Male Female Total 1. Married 63 49 112 56.3% 43.7% 64% 2. Unmarried 27 30 57 47.4% 52.6% 32.6% 3. Widow/er 0 6 6 100% 3.4% Total 90 85 175 51.4% 48.6% 100% Among the family members of international patients, 112 (64%) were married while 57 (32.6%) were unmarried and 6 (3.4%) were widows. Among the married members, 63 (56.3%) were males and 49 (43.7%) females. Among the unmarried members, 30 (52.6%) were females and 27 (47.4%) males (Table 5.14).

Table 5.15: Education-wise Distribution of Family Members Sl.No. Level of Education Percentage Male Female Total 1. Primary 3 14 17 17.6% 82.4% 9.7% 2. Secondary 22 33 55 40 60% 31.4% 3. Graduate 44 31 75 58.7% 41.3% 42.9% 4. Post Graduate/MBA 19 4 23 82.6% 17.4% 13.1% 5. MBBS 2 0 2 100% 1.2% 6. Illiterate 0 3 3 100% 1.7% Total 90 85 175 51.4% 48.6% 100% Looking at the educational level of the family members of international patients, 75 (42.9%) were graduates of which 44 (58.7%) were males and 31 (41.3%) females. There were 23 (13.1%) members who were post graduates out of which 19 (82.6%) CESS Monograph - 42 168 were males and 4 (17.4%) females. However, the female percentage was high among the members who were primary and secondary educated. Among the primary educated members, 14 (82.4%) were females and 3 (17.6%) males. Among those with secondary education, 33 (60%) were females and 22 (40%) males. And also 3 (1.7%) females were illiterates (Table 5.15).

Table 5.16: Occupation wise Distribution of Family Members Sl. No Category Occupations Percentage Male Female Total 1 Self Employed Business 38 4 42 90.5% 9.5% 24% 2 Professionals/ Employee Govt. job 6 2 8 75% 25% 20.5% Doctor 1 0 1 100% 2.6% Private job 18 11 29 62.1% 37.9% 74.3% Police 1 0 1 100% 2.6% Sub -Total 26 13 39 66.7% 33.3% 22.3% 3 Dependent Child 0 1 1 100% 1.1% Not working 1 43 44 2.3% 97.7% 46.8% Student 25 24 49 51.1% 48.9% 52.1% Sub -Total 26 68 94 27.7% 72.3% 53.7% Grand Total 90 85 175 51.4% 48.6% 100% The above table reveals the occupational structure of the family members of international patients. A majority of the family members (53.7%) are dependents, out of which 27.7% are males and 72.3% females. All the self-employed members (42) were into business, out of which 38 (90.5%) were males and 4 (9.5%) females. Family members who were self-employed or professional/employee were 24% and 22.3% respectively. Among the dependent family members, 49 (28%) were students, out of which 25 Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 169

(51.1%) were males and 48.9% females, followed by 44 non-working (25.1%) members, out of which 43 (97.7%) were females. A majority of the members who were professional/ employee were engaged in private jobs (74.3%), out of which 62.1% were males and 37.9% females. Professional category also included government job holders (20.5%), doctors (2.6%) and police (2.6%) (Table 5.16).

Table 5.17:Country-Wise Distribution of International Patients Sl.No. Region Countries Percentage Male Female Total 1. Africa Nigeria (West Africa) 2 2 4 Tanzania (East Africa) 1 2 3 Kenya (East Africa) 3 1 4 Uganda (East Africa) 1 0 1 (Southeast Africa) 1 0 1 Total 8 5 13 61.5% 38.5% 26% 2. Middle East Countries Oman 8 3 11 Yemen 3 2 5 Dubai 2 1 3 Iraq 1 2 3 Bahrain 0 1 1 Saudi Arabia 2 0 2 Total 16 9 25 64% 36% 50% 3. South Asia Bangladesh 2 1 3 Sri Lanka 1 0 1 Pakistan 0 1 1 Total 3 2 5 60% 40% 10% 4. Europe U.K. 3 0 3 Italy 0 1 1 Croatia 1 0 1 Total 4 1 5 80% 20% 10% 5. Australia 2 0 2 100% 4% Total 33 17 50 66% 34% 100% CESS Monograph - 42 170

The above table shows that a majority of the international patients coming to Mumbai for treatment were from Middle East countries. The data reveals that 25 (50%) came from Middle East countries (out of which 16 were males and 9 females), followed by 13 patients (26%) from Africa, (of which 8 were males and 5 females). There were 5 (10%) patients each from Europe and South Asia. Among the South Asian countries, 3 were from Bangladesh and 1 each from Sri Lanka and Pakistan. In Europe, 3 came from U.K. and 1 each from Italy and Croatia. There were 2 patients from Australia (Table 5.17).

The hospitals visited for the study receive patients from many countries. As per the qualitative data collected from hospital staff, most of the patients were from Middle East in respect of all the hospitals. Tata Memorial Hospital also received patients from Australia, Srilanka and Bangladesh. Patients also came from Ethiopia to Jaslok Hospital for treatment.

Most patients from Middle East countries visiting India may be due to the cultural and civilizational linkages as middle class Arab Muslim patients find Indian situation more adjustable vis-a-vis the West or US. Going by a paper based on a field survey of the medical tourists coming from the oil rich Arab Gulf States at various hospitals in New Delhi, about 38% of the respondents were from Iraq, 20 % from Oman,16 % from Kuwait,10 % from UAE, 4 % from Yemen, and 4% from Bahrain (Ahmad & Sikandar, 2014).

On examining the health problems of international patients coming to Mumbai for treatment, it was found that 12 (24%) had cardiac problems, 9 (18%) had orthopedic problems, 7 (14%) had cancer and neurological problems each. Among the patients having cardiac problems, males (9 or 75%) outnumbered females 3 (25%). Similarly, among the cancer patients, there were 6 (85.7%) males as against 1 (14.3%) female (Table 5.18).

Most of the studies show that medical tourists who came to India for treatment had cardiac, cancer, orthopaedic, gastro-intestinal problems, cosmetic surgery and even dental problems (Prakash et al, 2011; Sajjad, 2009; Kumar, 2009; Dhodi et al, 2014; Gupta et al, 2015). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 171

Table 5.18: Health Problems of International Patients Sl.No. WHO Classification of Diseases Health Problems Percentage Male Female Total 1. Infections and Parasitic Diseases Tuberculosis 1 0 1 100% 2% 2. Neoplasm Cancer 6 1 7 85.7% 14.3% 14% 3. Diseases of Nervous System Neurological problems 5 2 7 71.4% 28.6% 14% 4. Diseases of Circulatory System Cardiac 9 3 12 75% 25% 24% Vericose Veins 1 0 1 100% 2% 5. Diseases of the Digestive System Gastro Intestinal 2 2 4 50% 50% 8% Hernia of stomach 0 1 1 100% 2% 2% 6. Diseases of the Musculoskeletal Orthopaedic 5 4 9 System and Connective Tissue 55.6% 44.4% 18% Back Pain 0 1 1 100% 2% 7. Diseases of Genitourinary System Urology 1 0 1 100% 2% Gynecology 1 0 1 100% 2% Kidney Problem 1 1 2 50% 50% 4% 8. Others Master check up 1 2 3 33.3% 66.7% 6% Total 33 17 50 66% 34% 100% 5.4.3: Reasons for Coming to India This segment examines the reasons which prompted the international patients to come to India for treatment, the problems, if any, while applying for visa and the information about the type of visa. India's healthcare sector has made impressive strides in the recent years interms of providing cost effective healthcare solutions through skilled healthcare CESS Monograph - 42 172 professionals. As a result, the medical tourists come from the developed countries like the USA, Canada, UK, along with the West Asian as well as South East Asian regions mainly because of the high costs of medical treatment as well as undue waiting time in their respective countries. Moreover, Arab Muslim patients find Indian situation more adjustable than in the West or US.

Table 5.19: Reasons for Choosing India for Treatment Sl.No. Reasons Percentage 1. Low cost 10 20% 2. Specialized doctors 42 84% 3. Long waiting time in their country 6 12% 4. Combining vacation with treatment 3 6% 5. Treatment not available in their country 20 40% 6. Since Family stays here 1 2% Total 82 164% Note: Due to Multiple answers, the aggregate percentage may exceed 100 The above data reveals that the main reason for a majority of the patients coming to Mumbai for treatment is doctors' specialization. An overwhelming 84% of the patients reported doctors' specialization as the main reason behind choosing India followed by 40% who had come to India because treatment was not available in their country. Only 12% had come to India due to long waiting periods in their country, while for 20% of the patients, low cost was the reason for coming to India for treatment (Table 5.19). As per a study by Padiya and Goradara (2014), a majority of the patients consider doctors' specialization and treatment charges as the most important factors in the choice of a particular medical facility. Based on the data collected from foreign patients across various hospitals in Ahmedabad it was found that for 46% of the patients it was specialization of doctors and for 35% the low cost of treatment that attracted them to come to India. For eleven percent of the patients it was infrastructure at the hospital/s and only for 3% of the patients accommodation facility available at the hospital/s that Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 173 made them choose India. Patients seem to be least bothered about the hospitality of hospitals (Padiya & Goradara, 2014).

Table 5.20: Who suggested this Place and Hospital Sl.No. Who suggested the place Percentage 1. Friends/Relatives 15 30% 2. Doctors at their place 15 30% 3. Website 16 32% 4. Networks/Agencies 19 38% 5. Staff of the hospital 2 4% Total 67 134% Note: Due to multiple answers, the aggregate percentage may exceed 100

When asked who suggested this place and hospital, for 19 (38%) of the patients, it was agencies in their country who had suggested the hospital, 15 (30%) had been told by their friends and relatives, 15 (30%) had come to know of the hospital from doctors at their place, while 16 (32%) had come to know of the place and hospital from the website (Table 5. 20). In Mumbai, a little higher percentage of international patients had been informed of the hospital by agencies at their place. And more or less for an equal percentage of the patients, it was their friends and relatives, doctors at their place who had recommended the hospital and the website also had played an important role in this respect. According to other studies, most of the international patients had been informed by their friends and relatives about the hospital followed by website (Sajjid, 2009; Padiya and Goradara, 2014).

On being asked how they contacted the hospital, a majority of (39 or 78%) foreign patients said "through phone", 27 (54%) of the patients contacted online, 9 (18%) through consultants or agents, 2 (4.2%) through friends staying here and 3 (6%) through doctors at their place. Thus, phone and online were the main medium of contact for foreign patients, with the doctor/hospital. While a few had contacted the hospital through agents/consultants at their place (Table 5.21). CESS Monograph - 42 174

Table 5.21: Medium of Contact With the Hospital Sl.No. Medium of contact Percentage 1. Online 27 54% 2. Over the phone 39 78% 3. Through friends who stay here 2 4% 4. Doctor at our place 3 6% 5. Through consultant/agent 9 18% Total 80 160% Note: Due to multiple answers, the aggregate percentage may exceed 100. All the study hospitals provide on-line counseling to the international patients. Asian Heart Institute, Nanavati and Hinduja hospitals also have the facility of electronic transfer of medical reports.

Table 5.22: Facilities that Attracted International Patients to This Hospital Sl.No. Facilities Mumbai 1. Doctors' Specialization 50 100% 2. Treatment charges 8 16% 3. Infrastructure 34 68% 4. Accommodation 10 20% 5. Hospitality 11 22% Total 110 220% Note: Due to multiple answers, the aggregate percentage may exceed 100. For all the international patients, doctors' specialization was the main reason behind their choosing the hospital for treatment. Along with doctors, specialization, 34 (68%) Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 175 patients had been attracted by the infrastructure of the hospital; hospitality was the attraction in the case of 11 (22%) patients and for 10 (20%) patients, accommodation was also important (Table 5.22).

According to Sajjad, a majority of the patients (73.5%) were attracted by the quality of services available at the hospital; for 11.4% of the patients ease and affordability of travel was the reason to choose the hospital; a long waiting time in their country was the reason to choose the hospital in the case of 6.1% patients; and in the case of 9.1% patients, a high cost in their country was the reason (Sajjad, 2009).

Table 5.23: Difficulties faced by patients in their Country Sl.No. Difficulties in their country Percentage 1. Disease not being diagnosed properly 22 44% 2. Non availability of specialists 42 84% 3. Delay in getting appointments 9 18% 4. This particular disease is not covered under health insurance 12 24% 5. It is much expensive 7 14% 6. Came directly to India since family stays here 1 2% Total 93 186% Note; Due to multiple answers, the aggregate percentage may exceed 100

The above table shows that, 42 (84%) of the international patients had opted for treatment in India due to the non-availability of specialists with respect to specific problems in their own country. In the case of 22 (44%) patients, the disease was not diagnosed properly in their country and this particular disease had not been covered under health insurance for 12 (24%) patients, while in the case of 9 (18%) patients, there was a delay in getting appointment/s and for 7 (14%) patients, treatment cost was much expensive in their country. One patient had come directly to India since the family was staying here (Table 5.23). CESS Monograph - 42 176

5.4.4: Visa Foreigners, who come to India for medical treatment, need to get a valid visa along with their passports. To aid the medical tourism industry, a new category of visas for medical tourists has been started by the Indian Ministry of Tourism. These visas called "M" or medical-visas are valid for one year, but can be extended up to three years and are issued to a patient along with a companion. Efforts have also been undertaken to improve the airport infrastructure for ensuring a smooth arrival and departure of health tourists.

Table 5.24: Any Difficulties faced, While applying for Visa Sl.No. Any difficulties Percentage 1. Yes 3 6% 2. No 47 94% Total 50 100% On being asked whether they had faced any difficulties, while applying for visa, an overwhelming 47 (94%) international patients said that they had no problems, while only 3 (6%) had faced some kind of problems (Table 5.24). Table 5.25: Whether the Staff at the Indian Embassy Friendly and Helpful Sl.No. Whether the staff at the Embassy friendly Percentage 1. Yes 50 100% 2. No 0 Total 50 100% All the respondents felt that the staffs at the Indian embassy had been friendly and helpful (Table 5.25).

Table 5.26: Distribution of patients by Type of Visa Sl.No. Type of visa Percentage 1. Medical visa 48 96% 2. Tourist visa 2 4% Total 50 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 177

Out of the 50 international patients in Mumbai, an overwhelming 48 (96%) had come with a medical visa and only 2 (4%) had tourist visa (Table 5.26). However, a study by Prakash et al reveals that medical visa is costlier and cumbersome as compared to tourist visa. Therefore, many medical tourists coming to India prefer tourist visa to medical visa (Prakash et al, 2011).

Table 5.27: How Many Days Did You Get the Visa For Sl.No. Number of days Percentage 1. 1 month 1 2% 2. 2 months 3 6% 3. 3months 27 54% 4. 6 months 11 22% 5. 1 year 8 16% Total 50 100%

The above table shows that more than half of the international patients (54%) had got visa for 3 months, 11 (22%) for 6 months, and 8 (16%) for 1 year. The number of international patients with visa for 1 and 2 months was very less, i.e., 2% and 6% respectively (Table 5.27).

5.4.5: Medical and Travel Expenses This segment examines the medical and travel expenses of international patients, and whether they had planned to do some tourism, while being in India.

5.4.5a Insurance As the medical tourism industry continues to grow and gain popularity, health insurance companies are standing up and taking notice. Insurance companies are willing to provide care at medical tourism destinations, including waiving of deductible and out-of-pocket health expenses and paying for the travel of patients including even family members. CESS Monograph - 42 178

Table 5.28: Did they have Health Insurance? Sl.No. Whether having health insurance Percentage 1. Yes 29 58% 2. No 21 42% Total 50 100% The above table reveals that more than half (58%) of the international patients in Mumbai, had come with health insurance and 21 patients (42%) without health insurance (Table 5.28). Our study hospitals, namely, Asian Heart Institute, Nanavati, and Jaslok hospital, have tie-ups with insurance providers for facilitating international patients to access health insurance. Many studies show that, most of the international patients were self supported (Sajjad, 2009; Prakash et al, 2011; Sunita Maheswari,2012; Poonam Gupta et al, 2015).

Table 5.29: Would They Have Been Able to Come to India without Health Insurance? Sl.No. Whether able to come without health insurance Percentage 1. Yes 28 96.6% 2. No 1 3.4% Total 29 100% Almost all the medical tourists (96.6%) who had come with health insurance said that they would anyway have come to India even without insurance coverage. Only 1 (3.4%) said that he would not have been able to come to India without insurance (Table 5.29).

Table 5.30: Did the Health Insurance give Any Additional Incentive to Come to India? Sl.No. Additional incentive by health insurance Percentage 1. Yes 26 89.7% 2. No 3 10.3% Total 29 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 179

The above table reveals that in the case of 26 (89.7%) patients out of a total of 29 medical tourists who had come with insurance, their health insurance did give some additional incentive to come to India. Some insurance companies offer discounts to patients willing to go abroad for treatment. Almost in all the cases, the insurance company reimbursed some amount of their money spent (Table 5.30).

5.4.5b: Expenditure Complicated surgeries and treatment are made possible at almost 1/10th of the cost of developed countries in the developing countries like India. Indian medical tourism is being promoted as First World Treatment at Third World Costs. India is now being put up on the international map as a heaven for those seeking quality and affordable healthcare. This lower cost is especially important for a patient who does not have health insurance and also because a procedure may be financially crippling for a patient in the home country.

Table 5.31: Cost of Treatment and Stay Place Reasons Number Mean Std Devition Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) No idea till now 4 Didn't tell 1 Total 5

Mumbai Number of patients giving amount 45 6593.56 6122.02 392.75 37704.00 5498.50 Total 50

Out of the 50 respondents in Mumbai, 45 patients gave information about the cost of their treatment and stay in the hospital. Out of the 5 patients, who didn't give any information about the cost, 4 patients had no idea about the cost as their treatment was still continuing and one patient didn't want to tell. On an average, 45 patients, who gave information on the treatment cost, had spent $ 6593.56, ranging from a minimum of $ 392.75 to a maximum of $ 37704 (Table 5.31).

According to Sajjad, 86.4% of the medical tourists had thought that cost of treatment was nominal in India. However, a very small percent (7.6%) of the patients had thought that it was either expensive or cheap (Sajjad, 2009). CESS Monograph - 42 180

Table 5.32: Cost of the Entire Trip to India Place Reasons Number Mean Std Devition Minimum Maximum Median (In Dollars) (In Dollars) (In Dollars) (In Dollars) (In Dollars) The attendant had no idea 5 Didn't tell 1

Mumbai Total 6 Number of patients giving amount 44 7624.82 6870.96 242.65 43988.00 6998.88 Total 50

Out of the 50 patients, 44 gave information about the cost of their travel and trip to India. There were 6 patients who didn't give any information, out of which the attendant/ s of 5 patients had no idea about the cost nor were the patients in a position to speak. One patient didn't want to tell the details. On an average, 44 patients, who gave information, had spent $ 7624.82 on their travel to India, ranging from a minimum of $ 242.65 to a maximum of $ 43988 (Table 5.32).

The cost of medical procedure is low in India, however, the perceptions of the medical tourists reveal that they found other costs such as lodging and boarding also costlier (Prakash et al, 2011).

5.4.5c: Tourism Medical Tourism includes primarily biomedical procedures combined with travel and tourism. Thus, it includes the growing practice of patients travelling across international borders in search of a high quality medical care along with visiting a few tourist places in that country. India has been a tourist hot spot, luring foreigners predominantly because of its mysticism, spirituality, exotic locales, and a rich history and culture. India is an exotic tourist destination offering everything from modern medical treatment to traditional health care to enjoyment of visiting some awesome places of India.

When asked whether they had wanted to do any tourism, while being in India, a majority of the international patients (33 or 66%) responded in the negative, as they wanted to go back home soon, whereas 16 patients (32%) wanted to visit a few places in Mumbai Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 181 and elsewhere in India,while only 1(2%) was not sure as the treatment was going on (Table 5.33).

Table 5.33: Planning to do any Tourism, While being in India Sl.No. Any plan of tourism Percentage 1. Yes 16 32% 2. No 33 66% 3. Not Sure 1 2% Total 50 100%

Among the study hospitals, Cumballa, Jaslok and Hinduja hospitals arrange for medical tourism facilitator/s for international patients. Other studies also show similar results. Travelling was not an important aspect of their medical tourism. Medical tourists wanted to go back home as soon as possible (Sajjad, 2009; Reddy, 2013).

However, a study by Padiya & Goradara conducted among 100 patients in Ahmedabad reveals that, 60% of the medical tourists had come to India with the purpose of treatment with tourism, 34% for treatment with attending some social gatherings and only 6% for treatment along with shopping (Padiya & Goradara, 2014).

Most of the medical tourists who wanted to visit places in India, had planned to visit different places in Mumbai. A few also wanted to visit places outside of Mumbai like Agra, Hyderabad, Delhi and Rajasthan (Table 5.34).

5.4.6: Availability of Translators/Interpreters The language problem faced by Medical tourists is huge and affects a proper communication and makes things difficult for them to understand. In this context, interpreters play a very crucial role in sorting out language problems. This segment deals with whether the international patients had any problem with languages in India and whether the hospitals provided interpreters. CESS Monograph - 42 182

Table 5.34: If yes, Places You Would Like To Visit Sl.No. Places Percentage 1 Agra 1 2 Delhi ,Agra 1 3 Delhi ,Agra, Kashmir 1 4 Delhi, Mumbai 2 5 Gateway of India, Tajmahal 1 6 Mumbai 1 7 Mumbai, Agra, Kashmir 1 8 Mumbai, Delhi, Hyderabad 1 9 Mumbai, Goa, Agra 1 10 Mumbai, Goa, Rajasthan 1 12 Mumbai, Hyderabad 1 13 North India, Goa 1 14 Rajasthan, Delhi, Goa 1 15 Not Planned about the place 2 Total 16

Table 5.35: Problems with Language Sl.No. Problem with language Percentage 1. Yes 13 26% 2. No 37 74% Total 50 100%

Medical tourists coming from Africa and Australia could converse in English, while patients coming from Middle East countries had some problem with the language. The above table reveals that 37 (74%) did not have any problem with the language, while 13 (26%) faced difficulties in understanding the language. Thus, most of the international patients didn't face problems with the language (Table 5.35). Language is always a challenge for the non-English speaking medical tourists when it comes to conversing with the non-medical staff. Although 74% of the patients did not have problems with the language, all the hospitals visited have a provision for translators for international patients. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 183

Table 5.36: Whether the Hospital Provides Interpreter/s for those with language problem Sl.No. Availability of interpreter/s Percentage 1. Yes 13 100% 2. No 0 Total 13 100% All the 13 foreign patients, who faced problems with the language, said that they were being provided with interpreter/s (Table 5.36). In a study by Sajjad, among 132 foreign patients in Delhi, only 15.2% of the patients said that interpreters were available, while interpreters were not always available in the case of 84.8% patients (Sajjad, 2009). 5.4.7: Quality of Care This segment deals with the perceptions of the international patients regarding the quality of care provided at the hospital and the satisfaction level of patients.

Table 5.37:Problems during Admission at the Hospital Sl.No. Problems during admission Percentage 1. Yes 2. No 50 100% Total 50 100% The international patients did not face any problem during admission at the hospital (Table 5. 37).

Table 5.38:Whether the Staff was Courteous, Polite, Friendly and Helpful Sl.No. Whether staff friendly Percentage 1. Yes 50 100% 2. No Total 50 100% All the patients found the staff at the hospital courteous, friendly and helpful (Table 5. 38). Among the study hospitals, only Tata Memorial Hospital had a separate wing for foreign patients, though all the hospitals have a dedicated staff specially trained in handling the international patients. CESS Monograph - 42 184

Table 5.39: Procedures that the Doctor/s Suggested Sl.No. Procedures Percentage 1. X-ray 33 66% 2. Some specific diagnostic techniques 41 82% 3. Chemotherapy 1 2% 4. Routine Blood Test 17 34% 5. C.T.Scan 18 36% 6. Ultrasound 1 2% Total 111 222% Note: Due to multiple answers, the aggregate percentage may exceed 100. A majority of the foreign patients had been advised to undergo some specific diagnostic techniques (82%), followed by 33 (66%) patients advised to undergo X-ray, 18 (36%) had undergone C.T.Scan and 17 (34%) had been asked to undergo a routine blood test. The procedures prescribed by the doctor/s depended upon the health problem faced by the patient and the treatment he/she was undergoing (Table 5.39).

Table 5.40:Stages of Treatment Sl.No. Stages Percentage 1. Treatment is over 5 10% 2. Still continuing with treatment 34 68% 3. Regular checkup after treatment 8 16% 4. Come for treatment intermittently 3 6% Total 50 100% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 185

Most of the international patients contacted were still continuing with the treatment. Out of the 50 foreign patients, 34 (68%) were still continuing with the treatment and for 5 (10%) patients, the treatment was over. A few had come for treatment intermittently (3 or 6%) and 8 (16%) had come for regular check-ups after treatment (Table 5.40).

Table 5.41:Whether Satisfied with the Surgical Procedure Sl.No. Whether satisfied with surgical procedures Percentage 1. Yes 34 68% 2. No 0 3. No operation needed 7 14% 4. Not yet operated 9 18% Total 50 100%

All the foreign patients, who had been operated upon, were satisfied with the surgical procedure. Out of 50 patients, 34 (68%) were satisfied with the surgical procedure, while in the case of 7 (14%), no operation was needed and 9 (18%) were yet to undergo operation (Table 5.41).

Table 5.42:Whether Satisfied with the Doctor/s Sl.No. Satisfied with doctor/s Percentage 1. Yes 50 100% 2. No 0 Total 50 100%

All the 50 patients were satisfied with the doctor/s. Since all the patients had come to India because of the doctors' specialization, they were all satisfied with the doctor/s (Table 5.42). CESS Monograph - 42 186

Table 5.43: Whether Satisfied With the Care Takers of the Hospital Sl.No. Satisfied with care takers Percentage 1. Yes 50 100% 2. No 0 Total 50 100% All the 50 patients were satisfied with the care-takers of the hospital. The care takers in the hospitals in India are well trained in dealing with the international patients coming to India for treatment (Table 5.43).

Table 5.44:Whether the Hospital Providing Medicines Prescribed by Doctor/s Sl.No. Hospital providing medicine Percentage 1. Yes 49 98% 2. No 0 3. No medicine has been prescribed 1 2% Total 50 100% When asked whether the hospital was providing medicines prescribed by the doctor/s, 49 (98%) patients said 'Yes', while in the case of 1 patient, no medicine had been prescribed (Table 5. 44).

Table 5.45:Whether Information Regarding Recovery Given to Family by Doctor/Nurse Sl.No. Information regarding recovery Percentage 1. Yes 47 94% 2. No 0 3. Will tell after surgery 3 6% Total 50 100% For an overwhelming 47 (94%) of the international patients, information regarding recovery had been given to their family by the doctor/nurse, while 3 (6%) patients said that they would be told after the surgery was over, as the treatment was going on (Table 5.45). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 187

Table 5.46:Whether the Nurse/Doctor Explained the Purpose of medicine to be taken at Home Sl.No. Purpose of medicine explained Percentage 1. Yes 38 76% 2. No 0 3. Not yet 12 24% Total 50 100% On being asked whether the nurse/doctor explained about the purpose of medicine to be taken at home, a majority of the patients (38 or 76%) said that they had been explained about the purpose, while 12 (24%) said since their treatment was still going on, they had not been told as yet (Table 5.46).

Table 5.47:Whether Satisfied With Hygiene and Cleanliness at the Hospital Sl.No. Satisfied with hygiene Percentage 1. Yes 49 98% 2. No 0 3. Good as Compared to other places 1 2% Total 50 100%

Most of the international patients were satisfied with hygiene and cleanliness at the hospital. For 1 (2%) patient, it was good as compared to other places, while a majority of the patients (49 (98%) were very satisfied with cleanliness and hygiene at the hospital (Table 5.47).

Cleanliness and hygiene are one of the important factors attracting international patients to the hospital. In all the hospitals visited, hygiene and cleanliness are well maintained with the cleaning staff cleaning the premises at regular intervals.

The hospital provided accommodation for the attendant/s in the case of 41 (82%) patients, while 8 (16%) patients had to arrange accommodation for their attendant/s on their own and only 1 (2%) patient was not accompanied by an attendant (Table 5. 48). CESS Monograph - 42 188

Table 5.48: Whether the Hospital Provided Accommodation for the Attendant/s Sl.No. Accommodation for attendant/s Percentage 1. Yes 41 82% 2. No 8 16% 3. Do not have accompanying person 1 2% Total 50 100% Similar findings are found in a study by Sajjad. The accommodation for most of the international patients' attendants had been arranged by the hospital (Sajjad, 2009).

Table 5.49: If no, how Did They Arrange Accommodation for Attendant/s? Sl.No. Alternate arrangement of accommodation Percentage 1. Hospital arranged the accommodation 1 12.5% 2. Personal arrangement in an A star hotel 2 25% 3. Agent arranged all travel, visa, and accommodation 1 12.5% 4. Personally looked for a house near the hospital 4 50% Total 8 100%

Out of the 8 patients who had to arrange their own accommodation for attendant/s, 4 (50%) personally looked for a house near the hospital, while 2 (25%) made arrangement in an A star hotel and in the case of 1 (12.5%), the agent in their place had arranged all travel, visa and accommodation. In the case of 1 (12.5%) patient, the hospital had made arrangement for the attendant, but outside of the hospital (Table 5.49).

Regarding the quality of food provided in the hospital, 27 (54%) patients said that it was decent, while for 16(32%), it was excellent and only for 7 (14%) patients, it was dissatisfactory. Thus, 43 (86%) international patients were satisfied with food provided at the hospital (Table 5.50). Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 189

Table 5.50:Quality of Food Provided in the Hospital Sl.No. Quality of food Percentage 1. Excellent 16 32% 2. Decent 27 54% 3. Dissatisfactory 7 14% Total 50 100% The qualitative data also reveals that a special diet was provided to international patients in all the hospitals visited.

Table 5.51:Whether Received Any Information about their Discharge Sl.No. Information about discharge Percentage 1. Yes 25 50% 2. No 1 2% 3. Still continuing with treatment 21 42% 4. Not yet discharged 3 6% Total 50 100%

When enquired whether they had received any information about their discharge, about half (50%) of the patients replied in affirmation, 21 (42%) said since they were still continuing with the treatment, they had not been told about their discharge. In the case of 3 (6%) patients, the treatment was over, but they were yet to be discharged (Table 5. 51).

The doctor had prescribed medicine in the case of 23 (46%) patients after the treatment was over, while in the case of 25 (50%) patients, the treatment was not yet over and for 2 (4%) patients no medicines had been prescribed (Table 5.52). CESS Monograph - 42 190

Table 5.52: Whether the Doctor Prescribed any Medicine after their Treatment Was Over Sl.No. Whether any medicine prescribed by doctor/s Percentage 1. Yes 23 46% 2. No 2 4% 3. Not yet over 25 50% Total 50 100% As per other studies, in the post treatment stage, the medical tourists were more concerned with an easy discharge which included clear follow-up instructions and the settlement of bills. The patients were also concerned with the post treatment monitoring and availability of prescribed medicines in the home country (Prakash et al, 2014).

Table 5.53: Availability of medicine in their Country for those Medicine had been prescribed Sl.No. Availability of medicine in their country Percentage 1. Only in a few places 18 78.3% 2. Haven't checked 5 21.7% Total 23 100% Out of the 23 international patients, 18 (78.3%) said that the prescribed medicines were available only in a few places in their country, while only 5 (21.7%) patients had not checked where in their country the medicines were available (Table 5.53).

Table 5.54: Whether the Alternate of prescribed Medicine/s available in their Country Sl.No. Whether Alternate of medicine available Percentage 1. Yes 10 23.8% 2. Not Available 7 16.7% 3. Will take from India 1 2.4% 4. Did not know 24 57.1% Tota l 42 84% Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 191

The above table shows that, almost 57.1% of the patients did not know whether the alternate of the prescribed medicine was available in their country, while 10 (23.8%) said that it was available and 7 (16.7%) said it was not available. Only one patient said that he would buy the prescribed medicine from India itself (Table 5.54).

Table 5.55: Will you come back here For Follow up Treatment? Sl.No. Coming for follow up treatment Percentage 1. Yes 40 80% 2. No 1 2% 3. Might be coming 8 16% 4. No need for of follow up treatment 1 2% Total 50 100%

When asked whether they would come back for follow up check-ups, an overwhelming 40 (80%) patients said that they would come back for follow up check-ups, whereas 8 (16%) were not sure of coming back for follow up check-ups and 1 (2%) said that he wouldn't come back. In the case of 1 (2%) patient, there was no need for follow up treatment (Table 5.55).

Table 5.56: Would You Come here in Future, if required for Any Treatment? Sl.No. Whether coming to India in the future Percentage 1. Yes 26 52% 2. No 0 3. Can't say 24 48% Total 50 100% Out of the 50 international patients, more than half i.e., 26 (52%) patients said that they would come to the same hospital if they needed any treatment in the future, and 24 (48%) were not sure as of now (Table 5.56). CESS Monograph - 42 192

Competence of the doctor/s was the most important factor which drew the international patients to the hospital. Since most of the patients were satisfied with the doctor/s, they were willing to come back to the hospital in future, if any treatment was required.

Table 5.57: Would You Like to recommend to Others this Hospital in Your Country? Sl.No. Would suggest others Percentage 1. Yes 50 100% 2. No 0 Total 50 100% All the international patients expressed that they would recommend this hospital to others in their country. In fact, a few had already informed their friends and relatives about this hospital (Table 5.57). This may be one of the reasons why the number of international patients visiting all the hospitals has been increasing over the years. Hinduja hospital receives around 100 patients and Cumballa hospital around 50 patients in a year, while Asian Heart Institute receives 6 foreign patients per month. Kokilaben Dhirubhai Ambani hospital welcomes around 200 international patients per month. Nearly 2400 medical tourists had come for treatment in the year 2014. In Jaslok hospital, the number of foreign patients had increased from 40 in 2013 to 62 in 2014. Similarly, in Global hospital, the number had increased from 46 in 2013 to 80 in 2014. 5.5: Ethical Issues The first ethical issue revolves around the very nature of medical tourism and the idea that a tourist will travel from a rich country to a poor country mainly with a view to exploiting the destination country resources. In the case of medical tourism, this often amounts to using body parts from local people, which have either been purchased from them or taken after their death post an accident or execution. This type of exploitation shows the impact medical tourism can have on the local culture or society. Medical tourism may be seen as a clear example of the inequality of international relations between the rich and poor, north and south or first and third worlds, and raises the major concern that medical tourism often exploits the resources of a destination country. Although organ transplantation raises a number of ethical issues, the main two revolve around the origins of the organ and whether that organ is transplanted on to someone. These issues become especially complicated when applied to visitors who purchase organs Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 193 which, in turn, can, sometimes, lead to kidnap and murder of potential donors. Organs are traditionally sourced from a number of places and each has a differing ethical impact. Inspite of the national law which states that the sale of organs is banned, illegal organ transplantations have been on the rise in India. Some of the organs that are mainly donated include kidney, liver, heart, lung, etc. Here we have discussed mainly ethical issues involved in kidney transplantation, based on newspaper reports. In 2004, it was revealed that kidney transplantation had been going on in top hospitals in Mumbai. Poor people from Mumbai's slums and roads were lured into donating their kidneys in return for money. Again in 2007, an international kidney racket that spanned across Chennai, Mumbai and Gujarat was busted by Mumbai police. These are discussed below. The confession of Shivanand Damodar Kamat, a prime accused in the recently busted kidney racket, has led investigators to five top Mumbai hospitals. Kamat revealed that nearly 20 kidney transplants had been carried out in many hospitals in Mumbai. Following Kamat's confession, investigators have begun scrutinising the records of all kidney transplantations that have been conducted at five hospitals in the past few years (Patel, 2004). In 2005, a Mumbai court remanded the key accused, Mukhtar Ansari in a kidney racket in police custody till June 18. Ansari and two of his accomplices Juber and Javed, both under arrest, used to lure poor people from Mumbai's slums and roads into donating their kidneys in return for money, police officials said. On May 5, acting on a complaint filed by an Andhra Pradesh-based victim Mudanu Shrinivasan, who alleged that he had been promised money for donating a kidney, but never given anything. The police arrested four persons, including two doctors. Interrogation of those arrested revealed that, in April, Javed and Juber had befriended Shrinivasan and promised him Rs 3 lakh for selling his kidney. They admitted him to a nephrology clinic, owned by a man called Pravin Gujarathi, where some tests were conducted on Shrinivasan. After this, he was sent to Delhi, where his left kidney was allegedly removed. In Mumbai, Ansari is the lynchpin of the racket and this is how it is carried out: convince poor peopleinto donating kidneys, get their medical test done and arrange for the victim's travel to Delhi, where the operation is done. The gang members in Mumbai would then dress up the victim in brand new clothes and send them to Delhi by air. At the Delhi airport, their counterparts will identify the victims by their clothes. Once the victim is identified, they would be given some anesthetics and rendered unconscious. After the kidney is removed, the victims are sent to Mumbai by train (Singh, 2005). CESS Monograph - 42 194

According to , The Mumbai police (crime branch) in October 2007 arrested one Chennai doctor and four Mumbai-based touts for running an international kidney racket that spanned across Chennai, Mumbai and Gujarat. The accused confessed to running the racket since 2002 and conducting around 200 illegal transplants, with 100 kidneys being sourced from Mumbai alone. The kidneys were mostly given to foreigners from the Gulf, Sri Lanka and Myanmar. Senior Bombay Hospital doctor Suresh Trivedi had been involved in a similar scam in 2004. The process of getting the donor has remained the same over the years: touts hunt out the needy, befriend them over food and promise of money and conduct medical tests. Once the "donors"' kidneys seem fit, they are encouraged to "sell" them for lakhs of rupees. Documents are forged to show the donor and recipient as being distant relatives. The Transplantation Act says the donor and the recipient should be relatives or the donation should be out of affection or attachment, which is verified by an authorizing committee appointed by the government. The donor is, however, never given the promised money (TOI, 2007). Another ethical issue around medical tourism is surrogacy. The government emphasis on medical tourism , with the easy availability of surrogates, the clean medical facilities, and the presence of a large English-speaking population have drawn thousands of foreign couples to India ever since surrogacy was legalized in 2002. Today, leading ART clinics in the country oversee anywhere from 100 to 300 surrogate pregnancies every year. Commercial surrogacy has been permitted for more than a decade, but without government regulation, surrogates have to accept the terms that ART clinics give them. Most of the surrogate mothers in India are illiterate. Desperate for funds, they agree to the contract by thumbprint, without knowing what is written in English. A 2013 study conducted by the Centre for Social Research found that 88% of surrogate mothers interviewed in Delhi and 76% in Mumbai did not know the terms of their contract. In fact, 92% of those in Delhi did not even have a copy of it (Kumar, 2015). Because of the exploitation of poor women caused by commercial surrogacy, a PIL was filed by Jayashree Wad, an advocate on record in the Supreme Court since 1976. The Supreme Court has asked the Union government to respond to a PIL seeking a ban on commercial surrogacy, alleging that lax laws had allowed a rampant commercialization of motherhood, exploiting poor women to turn India into the world's surrogacy capital. Taking advantage of lax laws that allowed foreign couples to import embryo and transplant it on to Indian surrogate mothers, there had been a rampant commercialization of surrogacy in India which exploited women belonging to poor and lower middle-class strata of society. Narrating the possible impact of surrogacy on women who rent their wombs, the PIL said, "Large-scale exploitation of surrogate mothers in India involves Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 195 the danger of creating a section in Indian society which may suffer mental trauma due to social conditions. Giving birth to a child causes a huge impact on a woman's body and mind due to biological and hormonal changes". The PIL cited the in-vitro fertilization (IVF) clinic at Anand and said more and more foreigners were thronging the clinic to get a child through surrogacy at a cheap price. It said, "UN-backed study in 2012 estimated the surrogacy business in India to be more than 400 million pounds a year with over 3,000 fertility clinics"(Mahapatra, 2015). As a result, on November 2015, the Supreme Court imposed a ban on foreign nationals coming to India for surrogacy. In 2015, through the introduction of Assisted Reproductive Technology (ART) Bill, the Central government has narrowed surrogacy services to only Indian couples or foreigners married to Indian citizens. The commissioning parents must bear all the medical expenses, insurance etc, and are legally bound to accept the custody of the child/children irrespective of any abnormality the child/children may have, and whether the parents separate before the birth of the child/ children. After the court ban, the surrogacy industry would lose its best paying customer- the commissioning couples from other countries, thus leading to a decrease in medical tourism. Thus, the new bill tries to control and monitor the "baby making industry" and restrict the services only to needy and prevent unethical and exploitative practices of private clinics (Bindu, 2015; Mukherjee and Sekher, 2015). 5.6 Summary The health care sector in India has witnessed an enormous growth in infrastructure in the private and voluntary sectors. Quality care, relatively cheaper services compared to the west, package deals and cheap services from the tourism and hospitality sectors are the biggest attraction for medical tourism in India.Mumbai is one of the biggest cities in India with a prominent place in the world tourist map. This city is the center of all business and medical activities in the country and is considered as an ideal destination for medical tourists around the world. Mumbai medical tourism boasts of a large number of highly qualified medical professionals and state-of-the-art medical facilities. The city, with its vibrant life and friendly people, also makes the stay enjoyable. This chapter looks into the background characteristics, reasons to choose Mumbai for treatment, treatment expenses, visa issues, tourism related issues and the satisfaction level of the international patients coming to Mumbai for treatment. The background characteristics of the international patients reveal that more males came for treatment. Most of the patients were in the age group of 41 to 60 years with most of them married. Nearly 44% of the patients were graduates out of which 81.8% were males. Only 18% CESS Monograph - 42 196 of them were not working and 8% were students. The rest of them were into some kind of occupations with 32% being in business. The country-wise distribution of patients shows that, 50% came from Middle East countries followed by 26% from Africa. A very few were from Europe and South Asia also. Health problems of the international patients show that, 24% had cardiac problems and 18% orthopaedic problems. A majority of the patients had chosen Mumbai for treatment because of doctors' specialization (84%). A few had also come because treatment was not available in their country (40%). And in the case of 20% patients, low cost was the reason for coming to Mumbai for treatment. Regarding who suggested about the place and hospital, the patients in Mumbai were equally distributed with 38% suggested by agents/consultants in their country, 30% by their friends and relatives and 30% by the doctor/s from their place. The medium of contact with the hospital for most of the patients was either phone or online. Most of the patients did not face any difficulties while applying for visa and all the patients found the staff at the Indian embassy friendly and helpful. A majority of the patients (96%) had come with medical visa. Regarding health insurance, a little more than half the patients had come with health insurance (58%). However, they would have anyway come even without insurance. Almost in all the cases with insurance, the insurance company concerned reimbursed some amount of their money. The expenses of the treatment ranged from a minimum of 392.75 dollars to a maximum of 37,704.00 dollars. Travel and tourism is an integral part of medical tourism. Among the medical tourists in Mumbai, 66% were not willing to do any tourism after their treatment was over and only 32% wanted to visit places in Mumbai and also other parts of India. Most international patients were well versed in English, so language was not a problem for 74% of the patients. Those with the language problem were provided with interpreters/translators by the hospital. The international patients were overall satisfied with their experience in the hospital. They did not have any problem during admission and found the staff in the hospital very courteous, polite, friendly and helpful. They were all satisfied with the surgical procedure and the doctor/s. All the patients were satisfied with hygiene and cleanliness at the hospital. Accommodation was arranged by the hospital in the case of 82% of the international patients. However, 16% of the patients had to arrange their own accommodation, out of which 50% of the patients had looked for houses near the Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 197 hospital. Most of the patients were satisfied with food provided in the hospital, while only 14% were dissatisfied. A majority of the patients (80%) would come to the hospital for follow up treatment and 52% would come to the same hospital in future, if required, for any other treatment, while 48% were not sure. All the international patients said that they would definitely suggest others in their country about this hospital. CESS Monograph - 42 198

6. A Comparison of the findings across the cities of Hyderabad, Chennai and Mumbai

As discussed in the Introduction chapter, Medical tourism is a growing sector in India.India happens to be one of the first countries to have promoted medical tourism by offering special tax incentives to hospitals providing medical tourism. India's medical tourism sector was expected to experience an annual growth rate of 30%, making it a Rs. 9,500-crore industry by 2015. India has a large number of medical professionals and scientists in the world due to its long history of medical education and high investments in medical research. Moreover, due to a large population, Indian surgeons have more experience in some of the new medical techniques.There is a less bureaucratic delay in the acceptance of new medical procedures also.The cost of coming to India for treatment is also cheaper because of a number of airways and their cheap airfares. Even tele-consultancy is available for expert opinion. An increase in the number of medical tourists every year denotes that medical tourism is becoming increasingly popular in India despite the recession in the west. Many factors influence the patient's choice of a particular country for medical treatment. Healthcare comes at a much lower cost in the developing countries because of which patients are going to Brazil, Costa Rica, India, Malaysia, Philippines, and Thailand for medical treatment. Technology, competency and the availability of treatment options which may not exist at home also lure many medical tourists to a particular destination. In places like Canada and UK, the long waiting times for many non-urgent or elective procedures are the key reason driving patients abroad for medical treatment. Another reason why patients choose certain countries for medical tourism is the fact that these places are also attractive tourist destinations. Geographical proximity and cultural similarities are also reasons for their travelling to a particular country for medical treatment. One of the important factors that the patient considers while looking for medical care outside of his/her country is the accreditation of hospitals. Hospital accreditation ensures a high quality of treatment and care in a hospital and raises the confidence level of patients. Most of the hospitals visited in the three cities have been accredited. In Hyderabad, excepting Asian institute of Gastroenterology, all the hospitals visited have been accredited by NABH. Basavatarakam Indo American Cancer Hospital and Research Institute, CARE Hospital, Krishna Institute of Medical Sciences and Kamineni Hospital Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 199 also have NABL accreditation. Basavatarakam Indo American Cancer Hospital and Research Institute also have TUV (OHSAS) accreditation and Krishna Institute of Medical Sciences has ISO accreditation. In Chennai, all the hospitals visited, excepting Billroth Hospital, have been accredited by NABH. Global hospital also has NABL and HALAL accreditation, while Fortis Malar hospital has ISO accreditation. Similarly, in Mumbai, all the hospitals, except Camballa hospital, have been accredited by NABH. Kokilaben hospital and Hinduja hospital also have CAP accreditation. Asian Heart Institute, Hinduja hospital and Nanavati hospital also have ISO accreditation. All the hospitals visited across the three cities also provide special services for international patients like electronic transfer of medical reports, special diet, accommodation for patient's companion, on-line counselling, etc. A few hospitals like Basavatarakam Indo Americal Cancer Hospital and Continental hospital in Hyderabad, Billroth, Sri Ramachandra Medical centre and Fortis Malar hospital in Chennai and Sl Raheja and Kokilaben Ambani hospital in Mumbai have separate wings for international patients. The staff of all the hospitals visited across the three cities has been specially trained in dealing with international patients.However, this study depicts that most international patients come to these hospitals because of the specialized doctors rather than any other factor. Having analyzed the city-wise situations in the previous chapters, the present chapter attempts to draw a comparative perspective of the findings with regard to all the three cities. The main focus in this chapter will be on the background characteristics of the international patients, reasons for choosing India for medical treatment, details of medical and travel expenses and visa issues, and the perceptions of patients regarding the quality of care, availability of translators and care takers. 6.1 Background Characteristics of International patients across the three cities The first objective of the study was to find out the background characteristics of international patients. The data across the three cities reveals that the number of male patients is higher than female patients. Out of the 54 patients in Hyderabad, 59.3% were males and 40.7% females. Similarly, in Chennai, 68% were males and 32% females and in Mumbai, the number of males was 66% and that of females 34%. More patients were married than unmarried across the three cities. An age-wise distribution of the international patients reveals a similar trend across the three cities. In all the three cities, more patients were in the less than 50 years age category. Education-wise, more patients were graduates (38%), 26% were secondary educated and 24% primary educated in Chennai. In Hyderabad, more were primary educated (25.9%) followed by graduates CESS Monograph - 42 200

(24.1%). In Mumbai, graduates were 44% followed by secondary educated (24%) and post graduates (24%). Looking at the occupation of the patients, in Hyderabad, a little more than half of the patients were working in various kinds of occupation, 30% were not working and 15% were children. Similarly, in Chennai, more patients were into various kinds of occupation, 28% were not working, 6% were children and 8% students. In Mumbai, 18% were not working, 8% students and a majority were into various kinds of jobs (Figure 6. 1& 6.2). Figure 6.1: Gender of International Patients

Most of the studies reviewed also show that males coming for treatment outnumbered females (Prakash et al, 2011; Anvekar, 2012; Reddy, 2013; Dhodi et al, 2014; Poonam et al, 2015; Sujatha&Subhasini, 2015;). However, two studies show that females coming for treatment outnumbered males (Sajjad, 2009; Sunita Maheswari, 2012).

6.2 Countries of International Patients In Hyderabad, more than half the patients (55.6%) were from Africa followed by Middle East countries (27.8%). Out of 30 patients from Africa, 12 (40%) were from Nigeria (West Africa), 12(40%) from East Africa including Tanzania, Kenya, Somalia, Rwanda and Zambia, 5 from North Africa and 1 from Central Africa. The more number of patients from Nigeria may be due to the reason that Nigeria is one of the top 25 trading partners of India. A study by India's Exim Bank shows that trade between India and the Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 201

Figure 6.2: Distribution of International Patients by level of education

East African Community (EAC) has risen by 13-fold, from USD 490.8 million in 2002 to USD 6.6 billion in 2012 (SME Times, 2014). In Chennai, more patients were from Middle East countries followed by patients from Africa. There were 24 (48%) from Middle East countries and 23 (46%) from Africa. Out of the patients from Middle East countries, 17 were from Oman followed by 6 from Iraq. India and Oman across the Arabian Sea are linked by geography, history and culture. In Mumbai also, 50% of the patients were from Middle East countries. Out of the 25 patients from Middle East countries, 11 were from Oman followed by 5 from Yemen and 3 each from Iraq and Dubai. There were 26% from Africa, 10% from South Asia and Europe each and 4% from Australia. Thus, more patients were from Africa in Hyderabad, while in Chennai and Mumbai, more patients were from Middle East countries (Figure 6. 3). The more number of patients from Middle East countries may be due to the cultural and civilizational linkages as middle class Arab Muslim patients find Indian situation more adjustable than in the West or US. Moreover, Arab patients feel at home here as a number of restaurants serve their food here. The more number of patients from Oman in both Chennai and Mumbai may be because of the fact that both Oman and India CESS Monograph - 42 202

Figure 6.3: Country-Wise Distribution of International Patients

enjoy warm and cordial relations, which can be ascribed to historical maritime trade linkages, intimacy of the royal family with India and the seminal role of the Indian expatriate community in the building of Oman, a fact acknowledged by the Omani Government also. Bilateral relations between India and Oman have come a long way since 1955 when diplomatic relations with Oman were established with the opening of a small consulate in Muscat. Be it culture, communications, banking or connectivity between India and Oman, there is an increase in their engagements (The Week, 2010). 6.3 Health Problems faced by International Patients The health problems for which international patients come to India for treatment are varied and diverse. In Hyderabad, 13 (24.1%) came for cancer treatment, 22.2% for cardiac treatment, 11.1% patients for treatment of gastro intestinal problems and 9.2% each for treatment of neurological and ophthalmic problems. However, the presence of a large number of patients with cancer and cardiac problems may be due to the fact that most of the patients were from two specialized hospitals of cancer and heart. In Chennai also, a maximum number of patients came for cardiac treatment (18%) and 16% of the patients for treatment of neurological problems. International patients also came for the treatment of other problems like liver, kidney, urological, gynaecological, orthopaedic, and cancer. There was 1 patient each for plastic surgery and physiotherapy also. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 203

In Mumbai also, more number of patients had cardiac problems. Out of the 50 patients, 12(24%) had cardiac problems, 9(18%) orthopaedic problems, and 7 each (14%) cancer and neurological problems (Figure 6. 4). Figure 6.4: Health Problems faced by International Patients

Findings with respect the three cities thus show that the treatment of cardiac problems was sought by most international patients. In conformation to the present study, earlier studies also show that most of the international patients came for the treatment of cardiac problems (Santosh Kumar, 2009;Prakash et al, 2011; Dhodi et al, 2014). However, another study shows that most patients came for orthopedic treatment (Sajjad, 2009). Thus, international patients came to India for treatment of multiple systems which may include cardiac, orthopaedic, oncology, eye surgery, neurology and tumour treatment. 6.4 Reasons for coming to India Patients from the developed countries may seek medical treatment in another country to avoid the high costs and long waiting periods in their country. Patients with no insurance or underinsured may also seek treatment in other developing countries. People from under developed countries may opt for medical tourism due to the non-availability of specialized doctors and treatment in their country. A few also may look to combining tourism with treatment. CESS Monograph - 42 204

In Hyderabad, 90.7% of the patients gave specialization of the doctor/s as the reason for choosing India for treatment, while low cost of treatment was the reason for 31.5% of the patients for choosing India. And in the case of 18.5%, treatment was not available in their country. Long waiting time in their country was the reason for choosing India in the case of only 5.6% of the patients. In Chennai also, 98% of the patients chose India because of the specialization of doctors followed by 48% giving low cost of treatment as the reason for choosing India, and 12% came to India because treatment was not available in their country. Similarly, in Mumbai also, doctors' specialization was the reason for 84% of the patients for choosing India for treatment. In the case of 40%, treatment was not available in their country, while low cost was the reason for 20% of the patients. Only 12% came due to a long waiting time in their country. Thus, specialization of doctors seems to be the main reason behind choosing India for treatment, followed by the low cost of treatment in India (Figure 6.5).

Figure 6.5: Reasons for coming to India

In Hyderabad, more than half of the patients had been told about the hospital and place by their friends and relatives (68.5%). A few had been informed by the doctor/s at their place (38.9%). In Chennai also, 60% had been told by their friends and relatives and 46% by doctors at their place. However, in Mumbai, the numbers of patients were more or less equally distributed. A majority of the patients had (38%) come to know of the place and hospital from agencies in their country. Friends and relatives had suggested Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 205 about the place and hospital inthe case of 30% patients, 30% had been told by the doctor at their place. Regarding the medium of contact with the hospital, in Hyderabad, 75.9% of the patients had contacted the hospital online followed by 51.9% over the phone. In Chennai, almost the same number of patients had contacted over the phone and online. In Mumbai, a majority of the foreign patients had contacted the doctor and hospital over the phone and online and a few also had contacted through consultants or agents in their country.

On the lines of this study, two of the earlier studies reviewed also show that specialization of doctors was the main reason for medical tourists to come to India for treatment (Reddy, 2013; Padiya&Goradara, 2014). However, other studies also reveal that low cost was the main reason behind choosing India for treatment (Santosh Kumar, 2009; Anvekar,2012; Poonam Gupta, 2015). 6.5 Visa Foreigners, who come to India for medical treatment, need to get a valid visa along with their passports. A special visa called the 'medical visa' was introduced in India in 2005 to facilitate the international patients visiting India for treatment. The visa is valid for one year and requires the patients to register with the Foreigner Regional Registration Office within two weeks of their arrival. Most of the patients in all the three cities didn't face any problem, while applying for visa. In Hyderabad, 75.9% didn't face any difficulties, while applying for visa, 14.8% faced some problems. The patients felt that the staff at the embassy should be a little compassionate with people seeking visa for treatment purpose. In Cameroon, there is no embassy. The Counselor has to go to Nigeria to get visa, so he charges double the money. Moreover, it is very difficult to get medical visa. If the visa is urgent, they charge double the money. A few of the patients, therefore, prefer tourist visa. In Chennai, 94% of the patients didn't face any problem while applying for visa, while only 4% did face some problems. In Mumbai also, 94% of the international patients didn't face any problem, while applying for visa (Figure 6. 6& 6.7). In Hyderabad, 74.1% of the patients had come with medical visa, 9.2% had medical visa with a tourist visa for the attendant and 7.4% had come with a tourist visa only. In Chennai, 80% had medical visa, 8% tourist visa and 10% both medical and tourist visas. In Mumbai, 96% of the patients had come with medical visa. A majority of the patients in Mumbai had got visa for 3 months. However, a majority of the patients in both Hyderabad and Chennai had got visa for 6 months. CESS Monograph - 42 206

Figure 6.6: Whether faced difficulties, while applying for Visa

According to an earlier study, respondents had found the visa process in India cumbersome, where medically, the patient needs to reveal many documents to support his/her candidature for visiting India (Monika Goyal, 2014). However, most of respondents, according to another study, had rated it either good or satisfactory with regard to availability, cost, time taken and availability of extension. But still a significant number had expressed dissatisfaction regarding corruption, time taken and cost. This is an area which requires an immediate attention from our policy makers and the government (Poonam Gupta et al, 2015). Figure 6.7: Difficulties faced, while applying for Visa Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 207

6.6 Insurance Insurance companies play an important role in promoting medical tourism. One of the main reasons why people opt for medical tourism is that they have not been covered or partially covered by insurance. Some of the insurance companies also offer incentives to patients who are willing to go abroad for treatment. However, the present study shows a different picture. In Hyderabad, 88.9% patients had come without insurance and the rest of the patients who had come with insurance would have come even without insurance. For only one patient, it would not have been possible to come to India without insurance. In Chennai, 92% of the patients had come without insurance and 6% with insurance. The treatment of one patient was being sponsored by the government concerned. Out of the patients with insurance, 2 patients would not have been able to come without insurance. In Mumbai, however, more than half of the patients (58%) had come with insurance, while 42% without insurance. Most of those who had come with insurance would anyway have come to India even without insurance coverage (Figure 6.8). The studies reviewed also show that most of the international patients coming to India for treatment were self-supported. (Prakash et al, 2011 ; Sunita Maheswari, 2012; Reddy, 2013;Poonam Gupta et al, 2015). Figure 6.8:International patients with Insurance Coverage CESS Monograph - 42 208

6.7 Expenditure Indian medical tourism is being promoted as "First World Treatment" at "Third World Costs". Complicated surgeries and treatment are made possible in the developing countries like India at almost 1/10th the cost prevailing in the developed countries. This lower cost is especially important for a patient who does not have health insurance coverage and for whom a procedure may be financially crippling in the home country. In Hyderabad, the patients who gave information about their treatment cost, spent 5931.99 dollars on an average, ranging from a minimum of 29.91 dollars to a maximum of 23000 dollars. In Chennai, the average amount of money spent was11418.14 dollars, ranging from a minimum of 242.55 dollars to a maximum of 64680.00. In Mumbai on an average, the patients spent 6754.48 dollars,ranging from a minimum of 392.75 to a dollars and a maximum of 37704 dollars. In Hyderabad, both the minimum amount spent and the maximum was less as compared to Chennai and Mumbai. The expenditure depends on the type of health problems and duration of the stay in the hospital (Figure 6. 9). An earlier study reviewed also show that the amount spent by international patients for their treatment and stay was much less. As per a study conducted among 34 international patients in Bangalore, Hyderabad and Chennai, the minimum cost was $300 and maximum $16000. The average cost for treatment and stay was $6071 (Reddy, 2013). Figure 6.9: Expenditure incurred on Treatment and Stay Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 209

6.8 Tourism Medical Tourism combines two types of industries-healthcare and tourism. This includes people travelling to another country for treatment. Medical tourists look for countries with exotic locales for their treatment where they can visit a few places along with their treatment. In Hyderabad, only 38.9% of the patients wanted to visit different places after their treatment was over. The rest were not interested in any kind of tourism. In Chennai also, only 24% of the patients wanted to visit a few nearby places. In Mumbai, 32% of the international patients wanted to visit places after their treatment was over (Figure 6. 10). Figure 6.10: International patients interested in Tourism as well

The studies reviewed also reveal that tourism was not an important aspect of medical tourism as far as the international patients coming to India for treatment was concerned. Medical tourists did not want to do any tourism and only a very few wanted to visit a few places after the treatment was over (Sajjad, 2009). However, another study shows that medical tourists had come to India with the purpose of treatment with tourism (Padiya & Goradara, 2014). 6.9 Availability of Translators/Interpreters The role of interpreters is important in medical tourism as they help the patients having problems with the language communicate with doctors and healthcare providers. Mostly CESS Monograph - 42 210 affluent patients from Arab countries face a lot of problems with the language because of which there is a great demand for Arabic interpreters. In Hyderabad, however, a majority (75.9%) of the patients did not have any problem with the language, while only 13 patients did face some problem. Out of the 13 patients, only two patients were not provided with an interpreter, while the remaining 11 members were provided with an interpreter. In Chennai also, a majority (64%) of the patients did not have any problem with the language, while the rest of the patients (36%)with the language problem were provided with interpreters by the hospital. In Mumbai, 74% of the respondents didn't have any problem with the language, while 13 patients did have some problem and they were provided with interpreters by the hospitals (Figure 6. 11). Figure 6.11: Availability of Interpreters

However, an earlier study reviewed points out that most of the international patients with language problem were not always provided with interpreters by the hospitals (Sajjad, 2009). 6.10 Quality of care Patient satisfaction with the services provided is an essential indicator of quality of healthcare delivery. Depending upon the past experiences of patients or their family member and if the past performance of the service provider has been consistently satisfactory, customers have confidence in the service provider. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 211

Waiting Lounge for International Patients

Rooms for International Patients

Help Desk at the International Patients Wing CESS Monograph - 42 212

In Hyderabad, the overall experience of the international patients was satisfactory. A majority of the patients (94.4%) did not face any problem, while getting admitted, while only a few (3.7%) had some problems. One patient had to wait for a long time before the admission was done. Most of the patients found the staff in the hospital friendly, courteous and helpful. The patients were advised to go through all the routine tests before any treatment was advised, even if the patients had gone through all the tests in their country. All the patients who had undergone surgery were satisfied with the surgical procedure. A few were waiting for surgery and in a few cases, surgery was not required. Almost all the patients were satisfied with the doctor/s. Only three patients were not satisfied, as the doctor did not come for post-operative checkup. All the patients were satisfied with the caretakers of the hospital. In Chennai also, the patients were satisfied with their overall experience in the hospital. Only one patient had to wait for long before admission was done, while all the rest did not face any problem during admission. All the patients found the staff in the hospital helpful, courteous and friendly. All the patients who had undergone surgery were satisfied with the surgical procedure, while 40% of the patients had not yet been operated upon and in the case of 18%, no surgery was required. A majority of the patients (98%) were satisfied with the doctor, and all were satisfied with the care takers of the hospital. In Mumbai, all the patients were satisfied with the overall experience in the hospital. The patients found the care takers polite, courteous and helpful and they didn't face any problem during admission. The patients were advised to go through specific diagnostic techniques depending on the health problems. A majority of the patients (68%) were still continuing with the treatment and all of them were satisfied with their doctor/s. Most of the studies reviewed also reveal that, the medical tourists who had come to India were satisfied with the overall treatment and care in the hospital (Santosh Kumar, 2009; Sajjad, 2009; Anvekar, 2012; Reddy, 2013; Padiya & Goradara, 2014; Dhodi et al; 2014). 6.11 Hygiene and Cleanliness at the Hospital Most of the patients in all the three cities were satisfied with hygiene and cleanliness at the hospital. A few in Hyderabad found the hospital clean, but there was room for improvement. Three patients expressed that as compared to other places in India, the hospital was clean. However, the attendant of a patient in Hyderabad felt that the hospital was clean but was not sure of hygiene part. The security people would go inside Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 213 the ICU with their shoes on, while the attendants of the patients were asked to take off their shoes. In Chennai, 98% of the patients thought that the hospital was clean and hygienic. In Mumbai as well, 98% of the patients were satisfied with hygiene and cleanliness at the hospital and only 1 found it good as compared to other places. An earlier study also shows similar findings. Most of the international patients were satisfied with hygiene and cleanliness at the hospital (Anvekar, 2012). 6.12 Accommodation for Attendants Accommodation for the attendants of international patients is usually arranged by the hospital, concerned, one attendant is allowed to stay with the patient in the hospital. In Hyderabad, out of the 54 patients, for 94.4%, accommodation for attendants was provided by the hospital and the rest three patients did not have any accompanying attendants. In Chennai, in case of 88% patients, the hospital had arranged for accommodation for the attendants and the rest 12% had to arrange for accommodation on their own. Most of them arranged it in an A star hotel. In Mumbai, the hospital provided accommodation in the case of 41 (82%) patients, while 16% had arranged their own accommodation. Out of the 8 persons, who had arranged their own accommodation, 50% personally looked for a house near the hospital, 25% stayed in a hotel and in the case of 12.5%, the agent in their place arranged all-travel, visa and accommodation. Thus, in all the three cities, the hospital/s arranged for accommodation of the attendant/s accompanying the patient. Similar findings are revealed by a study reviewed that accommodation for the attendant was arranged by the hospital and that they were satisfied with the arrangement (Sajjad, 2009). However, another study shows that most of the international patients were staying in hotels. But those for who accommodation was arranged by the hospital were satisfied with the arrangement (Anvekar, 2012). 6.13 Quality of Food Regarding the quality of food, in Hyderabad, most of the patients were not satisfied with the food provided in the hospital. Only 16 out of 50 patients found the food decent and for 3 it was excellent. However, in Chennai, most of the patients were satisfied with the food provided in the hospital. Out of the 50 patients, 50% found the food decent, for 18% it was excellent, while for 8%, it was good. In Mumbai, only 14% of the patients were dissatisfied with the food, whereas the rest were satisfied with the food. This study, thus, shows a mixed response from the medical tourists across the three cities. CESS Monograph - 42 214

Earlier studies also show a mixed response. According to a study by Anvekar in Bangalore, most of the respondents were not satisfied with the food provided by the hospital, while another study conducted by Sajjad in Delhi, shows that more respondents were satisfied with the food provided by the hospital (Sajjad, 2009; Anvekar, 2012).

6.14 Whether they will come in future for any Treatment Depending upon their satisfaction level, the patients were asked whether they would come in the future, if any treatment was required. For follow up treatment, a majority of the international patients across the three cities said that they would come to the hospital.

In Hyderabad, almost all the patients (98.1%) were sure that they would come to the same hospital if they required any treatment in the future. In Chennai, 94% said that they would come in the future to the same hospital, if any treatment was required, while 4% were not sure. In Mumbai, 52% said they would come to the same hospital, while the rest 24% were not sure even though they were, overall satisfied with the treatment in the hospital. Thus, most of the medical tourists across the three cities were willing to come to the hospital in future for treatment, if required.

Similar findings have been found in the earlier studies. A majority of the international patients were willing to come back to the same hospital in the future for treatment (Padiya & Goradara, 2014). Another study, however, reveals that although most of the patients were satisfied with the overall experience in the hospital, a very few were willing to come back to the hospital in the future for treatment (Anvekar, 2012).

6.15 Would they suggest others about the Hospital and Country? A majority of the international patients in the three cities were of the opinion that they would suggest to others in their country about the hospital. In Hyderabad, 98.1%, 96% in Chennai and all the patients in Mumbai would suggest to others in their country about the hospital and country. Both in Chennai and Hyderabad, only 1 patient each would not suggest to others in their country about the hospital. Thus, most of the international patients across the three cities were willing to suggest to their friends, relatives and others in their country about the hospital (Figure 6.12). In fact, in Mumbai a few patients have already suggested to their friends and relatives about the hospital. Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 215

Figure 6.12: Suggestion to others about the Hospital

Similar findings have been revealed by the studies reviewed. Most of the respondents would suggest to others in their country about the hospital (Sajjad, 2009; Sunita Maheswar et al, 2012;Reddy, 2013). 6.16 Suggestions India has become a preferred health destination for many medical tourists who are looking for a speedy and inexpensive treatment. Indian health care providers try to attract international patients through the well trained medical specialists that they have, who have qualified from well known overseas institutes and also through the low cost of medical treatment. It also uses the technologies used by developed countries. And since medical tourism is a multi dimensional activity, it is necessary that all wings of the central and state governments, private sectors and voluntary organizations become active partners in the endeavor to attain a sustainable growth in tourism if India were to become a world player in the medical tourism industry. The present study has been conducted to look into the reasons why international patients choose India for treatment, their medical and travel expenses and their overall experiences during their treatment in the hospital. However, the study has brought to light a few points which need to be looked into. Visa: The study reveals that most of the international patients didn't face any problem while applying for visa. However, many patients were also of the view that it was very CESS Monograph - 42 216 difficult to get medical visa. And if the visa is urgent, they charge double the amount. Moreover, according to a few, the staff at the embassy should be more compassionate and caring towards those who are trying to get visa for treatment purpose. Usually, the patients are given single entry visa which becomes very inconvenient for those whose treatment is prolonged like patients who have come for the treatment of cancer. A few countries like Cameroon do not have Indian embassy, so the counselor has to go Nigeria for visa because of which they charge double the money and it is also a lengthy process. Another visa-related hassle is the requirement that foreigners periodically report to the police during their stay in India. All foreigners (including foreigners of Indian origin) visiting India on a long term (more than 180 days) Student Visa, Medical Visa, Research Visa and Employment Visa are required to get themselves registered with the Foreigners Regional Registration Officer (FRRO)/ Foreigners Registration Officer (FRO) concerned having jurisdiction over the place where the foreigners intend to stay, within 14 days of their arrival. However, Pakistan nationals are required to register within 24 hours of their arrival. This has not gone well with the international patients coming to India for treatment. In view of these problems, it is necessary for the government to look into this matter and ensure a speedy visa clearance and immigration by developing simplified systems of getting medical visas. Visa can also be extended depending on the condition of the patients. Language Problem: The research shows that English speaking capabilities of medical and paramedical staff is poor. Although almost all the hospitals visited had interpreters for the patients there were only a few interpreters in each hospital, sometimes only one, who were not always available. The Government and hospital/s should undertake programmes to train medical and paramedical staff in handling the international patients. There should be language training as well for catering to the needs of patients from countries of Middle East which is a major market, particularly Arabic. Access to data: A major constraint in the development of medical tourism is the attitude of hospital staff and the government towards research in this area. It is important for the hospital staff to support research in order to promote medical tourism. It was difficult to get access to data about medical tourists from various hospitals. Although several hospitals promote medical tourism in the three cities chosen, a very few of the administrators were enthusiastic about granting permission to interview their patients for this research. Moreover, it is also possible that some of the administrators were not providing the correct data. None of the administrators granted permission to examine hospital records in terms of the number of patients who had travelled to their hospitals and other demographic data. Again, the hospital staff was always present during the Study on Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai 217 interview with the patients because of which there was no transparency about the data given by the patients. Post Treatment Issues: The most significant issue related to medical tourism is the disproportionate shift of technology to the private sector for the care of international patients. Due to this, the local population may not benefit from the financial gains, as the money must be used to support the care required for international patients. Another issue related to medical tourism is the after-treatment complications (related to health and safety risks) to which medical tourists are exposed. These risks may include a deep vein thrombosis due to a long air travel after surgery, exposure to blood-borne diseases due to an inadequate blood collection, screening and storage protocols in the host countries and the risk of transmitting infections to their home country. Although medical tourists were encouraged to talk freely, it was evident that some health and safety risks were not spoken about. Information about the risks of medical tourism needs to be effectively transmitted to potential medical tourists. Tour operators: Unlike India, in Thailand, all the hospitals accepting foreign patients have tied up with tour operators. Hospitals, tour operators and respective state governments should come together to effectively promote medical tourism. India needs to work rigorously in this area.It is also necessary to develop supporting infrastructure such as transport services to facilitate tourism for the medical tourists. Websites: A few hospitals in India have their own websites, but they are not as vibrant as those in Thailand and Malaysia. Proper websites are the marketing strategy of the government of these countries to boost the number of inbound medical tourists to their country. The government of India should also start websites to attract international patients. The Central government can also help popularize medical tourism through embassies and Health Ministries in various foreign countries. Accreditation: Accreditation is important because it evaluates the most important factors and concerns that the patients consider while seeking medical care outside of their country. It ensures that quality of treatment is most important for all hospitals.Compulsory and world class accreditation of hospitals will improve the overall quality of services. This, in turn, will increase medical tourism. Insurance: Hospitals promoting medical tourism services should have dedicated travel desks. The insurance industry has become an active participant in medical tourism though many of the international patients interviewed particularly in Hyderabad and Chennai had come without health insurance coverage. The promoters should encourage CESS Monograph - 42 218 medical tourists to take up health insurance and ensure that they cover all kinds of health insurances provided in different nations. Hospitals should tie up with more and more multinational insurance companies so as to minimize the insurance related problems like reimbursement. Future Research: The complexity of international rules and norms influence the medical tourists' decision to travel to a particular country for treatment. It is required to set up a strong regulatory system, so that if anything goes wrong, it would be convenient for the medical tourists to take recourse to local courts or medical boards. 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K S Babu is an Associate Professor at Centre for Economic and Social Studies, Hyderabad. He has M.A. in Anthropology from Andhra University, Vishakhapatnam and Ph.D from University of Delhi, Delhi. He has 25 years of research experience in the fields of health care, health insurance, NGOs, rural development, tribal development etc. He has published articles in professional journals. He has co-edited (with Prof. S. Mahendra Dev) two books: India: Some Aspects of Economic and Social Development; and India's Development: Social and Economic Disparities. He was the Principle Coordinator for the recently concluded project, "Study on Water and Sanitation Programmes and Health Status of Communities: A Study of Three States, Madhya Pradesh, Odisha and Andhra Pradesh" and "Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai". His current research focuses on medical tourism, water and sanitation and tribal issues. Ipsita Mohanty is the Project Research Associate for the Project, "Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai" at Centre for Economic and Social Studies (CESS), Hyderabad. She has an experience in market research, freelancing on research assignments for 'TNS Mode'. She has M.A. in Sociology from University of Delhi, Delhi. P.Usha worked as the Project Research Associate for the recently concluded project, "Study on Water and Sanitation Programmes and Health Status of Communities: A Study of Three States, Madhya Pradesh, Odisha and Andhra Pradesh" and the study 'Medical Tourism in Three Metropolitan Cities: Hyderabad, Chennai and Mumbai' at Centre for Economic and Social Studies (CESS), Hyderabad. Currently, she is working as the Coordinator of the study, "Documentation of MIYCN (Maternal Infant and Young Child Nutrition) One Full Meal (OFM) Programme in Andhra Pradesh and Telangana". She did M.A. in Population Studies from Annamalai University, and has worked on Reproductive and child health.