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1. Healthy Business: Will Medical Tourism Be India’s Next Big Industry?: India Knowledge@Wharton
(http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4615)
Healthy Business: Will Medical Tourism Be India’s Next Big Industry?
Published : June 02, 2011 in India Knowledge@Wharton
In the past, U.S. President Barack Obama has singled out India for what
he sees as the country usurping American jobs and business. In May
2009, he removed some tax incentives for U.S. companies who allegedly
preferred to outsource rather than create domestic jobs. "Buffalo before
Bangalore" was his rallying call at the time. Now, India is back in his
crosshairs. In April 2011, he told a town hall gathering in Virginia that
Americans shouldn’t have to go to India or Mexico for “cheap” health
care. "I would like you to get it right here in the U.S.," he said. This is a single/personal use copy of India
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India Drug Action Network, told weekly newsmagazine India Today.
Others in India were equally critical and dismissive. But some have taken more serious objection. "Not
acceptable," says federal health minister Ghulam Nabi Azad. Affordable health care does not mean our
medicine is inferior to any superpower’s. I would like to say our medicines are indigenous, they are
superior, and superiority does not come by escalating costs."
The bone of contention is the word "cheap." Obama probably used the term in the sense of less
expensive. But Indians have interpreted it as meaning "tawdry and inferior." Analysts don’t expect
Obama’s political posturing to make any difference to the flow of U.S. medical tourists into India. But
there is a lurking fear, nevertheless, that a nascent sector could be hamstrung at birth.
There Is No Choice
"Patients do not travel to India for health care services because they have a choice and they choose to go
to India," says Ravi Aron, professor at the Johns Hopkins Carey Business School and a senior fellow at
The Mack Center for Technological Innovation at Wharton. "They travel to India because they have no
choice." Adds Rana Mehta, executive director, PricewaterhouseCoopers (PwC) India: "If patients see
value in what India has to offer, they will continue to come."
Indians feel aggrieved that they have been singled out. In medical tourism, the country is still a bit player.
According to a report by the Delhi-based RNCOS, which specializes in Industry intelligence and creative
solutions for contemporary business segments, India’s share in the global medical tourism industry will
reach around 3% by the end of 2013. The December 2010 report -- titled "Booming Medical Tourism in
India" – says that the industry should generate revenues of around US$3 billion by 2013. "The Indian
medical tourism industry is currently in its early growth stage," says RNCOS chief executive Shushmul
Maheshwari.
Guess who’s the biggest beneficiary of medical tourism? It’s the U.S. "The largest segment, with 40% of
all medical travelers, seeks the world’s most advanced technologies," says a McKinsey & Co paper titled
"Mapping the market for medical travel." "These men and women take their search for high-quality
medical care global, giving little attention to the proximity of potential destinations or the cost of care.
Most such patients travel to the U.S." What worries the Indian industry is that this is not the first attack on
Indian medical tourism. In August last year, leading medical journal The Lancet had published an article
about a new superbug which it called the New Delhi metallo-beta-lactamase 1 (NDM-1). "The potential
of NDM-1 to be a worldwide public health problem is great, and coordinated international surveillance is
needed," said the article. Later, a co-author noted that some material had been inserted into the article
without his knowledge; the editor of The Lancet had to apologize for naming the bug after New Delhi,
and the Indian ministry of health had to weigh in. "The conclusions are loaded with the inference that
these resistance genes/organism possibly originated in India and it may not be safe for U.K. patients to opt
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2. Healthy Business: Will Medical Tourism Be India’s Next Big Industry?: India Knowledge@Wharton
(http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4615)
for surgery in India," said the ministry. "The medical journal's claim is not supported by any scientific
data and thus tarnishes the reputation of the country." Rightly or wrongly, the government and many in
India’s medical establishment believe that naming the superbug New Delhi was to keep U.K. medical
tourists at home. "The superbug certainly garnered a lot of media attention given its name," says Preetha
Reddy, managing director of Apollo Hospitals.
It won’t keep medical tourists at home, just as Obama’s appeal is likely to be ignored. "People will always
weigh the cost and the benefit," says Reuben Abraham. "If there is a 10% saving and there is a danger of
the superbug then chances are that people will not want to take it. But if you are offering an 80%
discount, it is a different matter. If India continues to offer high quality health care at one-tenth the cost in
the U.S. then these things will not make an impact."
The Next Big Thing
If all this is going to have limited impact, why is India getting so agitated? The answer lies in the
potential of medical tourism. It could easily be the next big thing. Unlike business process outsourcing
(BPO), which is on the whole very low-tech, health care -- particularly sophisticated procedures -- is very
high-tech. India has not been able to set up an adequate health care infrastructure for its own citizens and
it doesn’t have the money to do so. Creation of a sophisticated medical tourism structure will have a
trickle-down effect.
"India has the highest potential in medical tourism in the world," says Maheshwari of RNCOS. "Factors
such as low cost, scale and range of treatments differentiate it from other medical tourism destinations.
Moreover, growth in India’s medical tourism market will be a boon for several associated industries,
including the hospital industry, the medical equipment industry, and the pharmaceutical industry."His
study shows that CAGR (compound annual growth rates) in revenue in 2011-13 will be 26%. In terms of
medical tourists, the number would touch 1.3 million by 2013 at a CAGR of 19%. "Medical tourism can
be considered one of the rapidly growing industries in the Indian economy on the back of various
factors," he says. "However, the industry is at a nascent stage and requires a few years to reach the
platform already established by the IT sector." "India has been ranked among the top five destinations for
medical tourism," says Rana Kapoor, founder, managing director and CEO of Yes Bank, which has
recently done a study on health and wellness tourism in India along with apex chamber of commerce
FICCI. The ranking by Nuwire Investors, an online source for news on alternative investments, puts
Panama on top, followed by Brazil, Malaysia and Costa Rica. "India is looking at exponential growth as
far as tourism is concerned," continues Kapoor. "Yes Bank forecasts that there will be an increase in
domestic tourist movements over the period (2008-2020) by 118% and foreign tourist inflows over the
same period will increase by 71.87%. What the potential for medical tourism from within this growth rate
of 71.87% will be depends upon government policies, faith of the patients and many other external
factors. We truly believe that this sector will play a significant role as a contributor towards the overall
tourism growth in India."
"I strongly believe that many developments across the world will put India in a fantastic position," says
Devi Shetty, cardiac surgeon and chairman of Narayana Hrudayalaya. "We produce the largest number of
doctors, nurses and medical technicians in the world. Also, we have been traditionally linked with
western health care because of the British influence on our medical education and the ability to speak
English. This is extremely important for developing [global] health care. Our greatest asset is our ability
to produce the largest number of technically-skilled individuals. We also have the largest number of
USFDA (U.S. Food and Drugs Administration)-approved drug manufacturing units outside the U.S."
Differences over Terminology
Shetty doesn’t like the term medical tourism. "Medical care is something that is very stressful and people
consider this under tremendous pressure," he says. "It is an event where people are scared of losing their
lives. It may not be appropriate to call it tourism. Tourism is a different business altogether." Adds Mehta
of PwC: "The tourism component is really very weak. Most foreign patients come to India for chronic and
serious medical treatment and I would call it medical value travel." Aron of Johns Hopkins has yet
another view. "The world over it is known as the global health care delivery system," he says. Reddy of
Apollo agrees with Mehta. Says she: "At Apollo Hospitals, we prefer to term this business opportunity as
‘medical value travel’ as people travel to our hospitals for serious life threatening health conditions, which
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3. Healthy Business: Will Medical Tourism Be India’s Next Big Industry?: India Knowledge@Wharton
(http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4615)
essentially need highly skilled doctors and medical infrastructure and not mere minor treatments like
cosmetic enhancements, dental work or wellness which can be coupled with holidays, as the term
‘medical tourism’ implies."
The multiplicity of names is accompanied by a wide range of numbers. The confusion was started by the
McKinsey study on Mapping the Market mentioned earlier. The May 2008 report said that "medical
travel has captured the world’s attention and imagination". But it went on to explain that the McKinsey
definition of medical traveler was very different from what many others thought him to be. The first to be
knocked off were expats looking for health care in their country of stay. That accounted for 25-30% of
the traditional medical tourist pool. Then was the segment categorized under emergencies. These were
ordinary tourists caught up in accidents. That eliminated another 30-35%. McKinsey estimated the
remaining at "between 60,000 and 85,000 inpatients a year", much lower than generally accepted
numbers. For instance, a 2008 Deloitte Center for Health Solutions report on "Medical Tourism:
Consumers in Search of Value" put the number of Americans who had traveled abroad for medical care
in 2007 at 750,000. McKinsey excludes "wellness" tourists (acupuncture, spas, yoga, aromatherapy and
the like), patients from neighboring countries, and outpatients -- those who don’t need to check into
hospital.
The Deloitte report says that India is stepping on the gas; the medical tourism sector is expected to grow
30% annually up to 2015. An update on the report says that the U.S. recession is driving more people out
of the country for health care; U.S. outbound medical tourism is projected to increase 35% annually from
2010-2012. "Medical tourism [today] represents the maturation of a cottage industry," the report sums up.
Maheshwari of RNCOS agrees that economic problems are driving more Americans abroad for health
care. "Under almost stagnant salary increments, the disposable income and saving considerations of U.S.
citizens are still well below the pre-crisis levels," he says. "In this scenario, the low cost treatment and
nearly zero waiting time coupled with its proven track record offer convenient procedures for tourist
arrivals from various geographical locations including the U.S."
"Over the past few years, the medical tourism story has changed dramatically in India," says a recent
Cover Story in weekly business magazine BusinessWorld. (That it made it to the Cover is a reflection of
the growing importance of the sector.) "Not because the government has figured out the solution. But
purely because of private enterprise -- with a few corporate hospitals, chemists and freelance agents all
working in tandem to build a thriving ecosystem that educates, facilitates and ferries medical tourists from
across the world. Last year, this ecosystem was responsible for about 600,000 patients travelling to India
and spending US$1 billion in getting treated here. (The numbers are industry estimates as the government
does not have any official statistics on the subject.) Corporate hospitals such as Apollo, Fortis Hospital
and Max as well as business associations estimate that the business is growing by 40% year-on-year."
(Obviously, the growth numbers vary depending on who you talk to.)
Other Markets Will Turn to India
"India’s potential is huge," says Mehta of PwC. "Some 80% of foreign patients coming to India are from
the neighboring countries and from Iraq, Afghanistan, the former Soviet Union, etc and now increasingly
from Africa. But now with India proving itself as a credible provider of value health care, the western
population ageing, and health care becoming more difficult there, I expect more people to come from the
U.S. and the U.K."
Mehta says that some things went wrong with the earlier planning. "We expected most patients to come
from the U.S. and Europe. We expected people to come for cosmetic and regenerative treatment and this
is where there is more potential for tourism. But the majority actually came for cardiac treatment, cancer
treatment, knee replacement and other serious ailments. Therefore, tourism was not really of importance.
We did not get the cost factor right. We thought that typically in India it costs one-tenth of that in the
U.S., so we could cost at 5X. But hospitals have not been able to charge very much. At present, with a
foreign patient, there is around 20% more earning."
Cost is, of course, being underplayed in the marketing efforts; this is why the word "cheap" rankles. "The
patient is usually acutely aware of the difference in the sticker price for care," says Aron. "There is no
reason to draw attention to this.
”That’s an area where India enjoys an advantage over other countries too.
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4. Healthy Business: Will Medical Tourism Be India’s Next Big Industry?: India Knowledge@Wharton
(http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4615)
According to the BusinessWorld report, a heart bypass surgery costs US$144,000 in the U.S., US$25,000
in Costa Rice, US$24,000 in Thailand, US$20,000 in Mexico, US$13,500 in Singapore, and US$8,500 in
India. "The quality is excellent," says Maheshwari. In India, there is also less waiting time and
personalized services.
Becoming an Industry
Medical tourism is also taking shape as an industry, though there are some who feel that it will eventually
fall in many buckets. (The recent FICCI-Yes Bank study talks of wellness tourism, health tourism...)
"There are over 3,371 hospitals and around 750,000 registered medical practitioners," says Maheshwari.
Shetty says it is easier to get loans these days. "Earlier, it was difficult for us to mobilize huge financial
support to create large hospitals. However, things have changed now," he explains. Indian companies are
also taking over hospital chains in Asia -- Fortis has gone on a shopping spree, though it’s not been
entirely successful -- and setting up front-ends in other countries for marketing purposes. Apollo has
facilitation centers in Oman, Nigeria and the U.S. Max is present in Nigeria, Afghanistan, Bangladesh and
Nepal. Says Reddy of Apollo: "There are several key players. Apollo Hospitals continues to attract the
largest numbers of international patients followed by Max, Fortis and Workhardt."
"Another opportunity that Indian operators are now seeing is that you don’t have to offer these health care
services from India," says Abraham of ISB. "For instance you can offer it from say, Cayman Islands or
the Bahamas. Ultimately, the innovation is in the process and as long as you can bring the same process
innovation, even if the cost goes up a little as compared to offering it from India, it will still be a
substantial saving for the patient."
This is one area where China is no threat. Foreigners in China still rush to Hong Kong when they need
treatment because they cannot communicate with local doctors.
But what the budding sector will have to contend with is the Indian government. Take one example. With
the intention of making things smoother, the government introduced a medical visa (M visa), which was
faster and easier to get. In its wisdom, however, it added a peculiar clause -- "Foreigners coming on M
visa will be required to get themselves registered mandatorily well within the period of 14 days of arrival
with the concerned Foreigners Regional Registration Office." The end result: even patients who have to
be carried into India on stretchers are coming on tourist visas. If the government wants medical tourism to
be the next big thing, it has to put its house in order.
As for the immediate controversies, Shetty is very clear. "President Obama’s statement or the New Delhi
superbug will not affect medical tourism development in India," he says. "First of all, he was not
criticizing India. He was just trying to put his house in order."
This is a single/personal use copy of India Knowledge@Wharton. For multiple copies, custom reprints, e-prints, posters or plaques, please
contact PARS International: reprints@parsintl.com P. (212) 221-9595 x407.
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