News Medical visas mark growth of Indian medical tourism India’s medical tourism sector is a growing source of foreign exchange as well as prestige and goodwill outside the country. Having supported medical tourism’s rapid growth, the government is under pressure to find ways to make the sector of benefit to public health services that are used by most of India’s 1.1 billion population.

Indian consulates and missions abroad invasive surgery, oncology services, or- face a growing number of inquiries thopaedics and joint replacement, and about “M” or medical visas. holistic health care, provided by about The Indian Ministry of Tourism’s 45 hospitals promoted as “centres of 13 overseas offices are stocked with -in excellence”. formation for those intending to travel Health tourism is often hailed as to India for medical treatment. The a sector where developing countries, new M-visas are valid for a year and are such as India, have huge potential due issued for companions too. to their comparative advantage based Howard Staab, a 53-year-old from on providing world-class treatment at the United States, is one such tourist. low prices combined with attractive His smiling face figures in the glossy resorts for convalescence. brochure on medical tourism produced The CII estimates that 150 000 as part of Incredible India, the govern- medical tourists came to India in 2005, ment’s big-budget marketing campaign based on feedback from the organiza- to attract tourists. tion’s member hospitals. Figures for India’s efforts to promote medical M-visa entrants are not readily available. tourism took off in late 2002, when CII spokesperson Aditya Bahadur told the Confederation of Indian Industry the Bulletin that patients prefer to come

(CII) produced a study on the country’s on ordinary tourist visas to avoid the SEARO/WHO medical tourism sector, in collabora- M-visa’s requirement that they register Woman being treated for cholera in poor-resourced Indian hospital. The contrast between some public tion with international management with the regional authorities within two hospitals and the new centres of medical excellence consultants, McKinsey & Company, weeks of arrival. in India is stark. which outlined immense potential for A ministry of tourism brochure the sector. predicts a “phenomenal expansion” laboratory, while fewer than one in five The following year, then finance of the Indian health-care industry. have a telephone connection, according minister Jaswant Singh called for the According to the Federation of Indian to the 2005 Reproductive and Child country to become a “global health des- Chambers of Commerce and Industry, Health Facility Survey. Moreover, fewer tination” and urged measures, such as the health-care market, which includes than one in three primary health-care improvements in airport infrastructure, health insurance, is expected to expand centres stocked essential drugs, in to smooth the arrival and departure of by 2012 from US$ 22.2 billion, or contrast to the situation in many new medical tourists. 5.2% of gross domestic product (GDP), urban medical centres. Medical tourism is an example of to between US$ 50 billion and US$ 69 Health care in India’s rural districts how India is profiting from globalization billion, or 6.2% and 8.5% of GDP. is poor, dogged by shortages of trained and outsourcing. It is also a new form While impressive, these figures do health workers, a lack of funds and cor- of consumer diplomacy, whereby for- not address the divide between facili- ruption. Many patients resort to quacks eigners who receive medical services in ties oriented towards medical tourism or seek no medical care at all, since India help the country to promote itself and those that cater to the health needs private practitioners are beyond the as a business and tourism destination. of the average, usually rural, Indian. means of most. India hosts medical tourists from According the World Health Orga- In contrast, to provide a guarantee industrialized countries, such as the nization (WHO), private expenditure of service quality for medical tour- United Kingdom and the United States, on health as a percentage of total expen- ists, the Indian Ministry of Health has but also from its neighbours Bangla- diture on health in 2003 was 75%. That begun accrediting hospitals and recom- desh, China and Pakistan. It faces in- contrasted starkly with government mending prices for services. So far 35 tense regional competition in this sector, expenditure of 25% in the same year, hospitals have applied for accreditation. particularly from Malaysia, Singapore a portion which finances public health CII has a certification system and and Thailand. facilities that cater to most of India’s has already approved 30 of its 120 hos- A wide-range of services are on population. pital members. Under the CII system, offer. Ministry of tourism brochures Fewer than 50% of India’s primary certified hospitals must agree to limit advertise cardiac surgery, minimally health centres have a labour room or a charges to foreigners as part of a dual

164 Bulletin of the World Health Organization | March 2007, 85 (3) News pricing-system that offers domestic pa- The private sector hospitals argue There are fears, however, that medi- tients lower prices. Non-resident Indian that trickle-down payments for hotels cal tourism could worsen the internal medical tourists are charged the same and other services will improve the brain drain and lure professionals from as any others from abroad. economy as a whole. But public health the public sector and rural areas to take Still, even these lower prices are advocates say that, unless the Indian jobs in urban centres. too high for the vast majority of India’s government actually allocates more of “Although there are no ready 1.1 billion population. The CII group, its revenues to public health systems, figures that can be cited from studies, which also has an ethical code for mem- the impact will be negligible. initial observations suggest that medical ber hospitals, is establishing a regulatory “The government has not examined tourism dampens external migration framework for its own members, raising how our patients will benefit [from but worsens internal migration,” said questions about how effective such self- medical tourism] or whether they will Dr Manuel Dayrit, director of WHO’s imposed rules can be. lose out,” Dr Nilima Kshirsagar, dean of Human Resources for Health depart- CII lawyers are also drawing up a one of Mumbai’s largest public hospi- ment. standard contract to ensure that any tals, the King Edward Memorial, told “It remains to be seen how sig- litigation, arising from treatment, is the Bulletin. “The need to benefit Indian nificant these effects are going to be. dealt with in Indian courts. Currently, patients is the main goal, and medical But in either case, it does not augur neither medical tourists nor Indian tourism cannot be at their cost.” well for the health care of patients who patients can take their cases to Indian Prime Minister Manmohan depend largely on the public sector for courts. Their only recourse is India’s Singh recently acknowledged the need their services as the end result does not State and National Consumer Disputes improve public health care: “There contribute to the retention of well- Redressal Commissions, which have a are many parts of our country where qualified professionals in the public huge backlog. public-sector intervention in health is sector services,” Dayrit said. “Any litigation launched against absolutely essential to carry conviction Dayrit disagreed with medical tour- an Indian hospital will expose the poor with our people and to improve the ism proponents, who argue that some system of justice that exists here,” said quality of delivery of services.” revenues from medical tourism will find Dr Mohan Thomas, medical direc- As the medical tourism sector their way into public coffers to help tor of the Cosmetic Surgery Institute grows, however, little is known about retain staff in the public sector. “Unless in Mumbai and Chairman of CII’s the impact this is having on its health national laws or regulations are set up so Healthcare Committee. workforce. Private hospitals argue that that these revenues are taxed explicitly But while helping to strengthen medical tourism reverses the brain drain and channelled to the public sector to medical tourism, the Indian government and that health workers, who are mi- augment salaries, the likelihood of this is coming under increasing pressure to grating to economies where salaries are happening is very slim,” he said. O use these foreign exchange revenues to higher and career opportunities more Rupa Chinai and Rahul Goswami, benefit the ailing and under-resourced attractive, will stay in India if they can Mumbai public health system. work in the medical tourism sector.

scientists to do more research relating Navy labs play public health role to public health problems. NAMRU’s research often involves A United States network of laboratories, initially created to protect the health of US service local children because their immune personnel by doing local research and disease surveillance, has become a major public systems are the best approximate to health presence in the developing countries where it operates. those of US military personnel and any- one who has not developed immunity to local diseases. “We are most interested in how When bird flu was first detected in over the years, NAMRU’s work has be- Egyptian children react to diseases Egypt in February 2006, it was a US come part of the public health systems because they are seeing the region’s naval laboratory that confirmed the of the developing countries where it is diseases for the first time. Human body samples received from Egypt’s govern- based. immune systems have memories, and ment laboratory were of the H5N1 Since NAMRU was founded in the children’s systems aren’t fully devel- sub-type, before forwarding them to 1940s, it has become the largest overseas oped to their habitat,” Captain Robert the US Centers for Disease Control military medical research facility in the Frenck, Jr was quoted as saying in and Prevention (CDC) for further world and emerged as an important for- All Hands, the US navy magazine in confirmation. eign policy vehicle of the United States. February 2004. “Keeping sailors, soldiers, airmen US naval personnel and scientists Andrew Stegall, public relations and marines healthy and out of hos- at these centres in Egypt, Ghana, officer at NAMRU-3 in Egypt, said it pital” is still the United States’ Naval Indonesia and Peru collaborate with lo- was mutually beneficial because they Medical Research Units’ (NAMRU) cal research groups, particularly in the share their findings with the local au- primary and original mission, accord- areas of vaccine development, disease thorities: “This gives the country a start ing to Andrew Stegall, public relations surveillance and vector control for process of developing their own capabil- officer at NAMRU-3 in Egypt. But, tropical diseases. They also train local ity of surveillance and treatment”.

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