MEDICAL TOURISM CASE Saksham Gupta | 39C | Saurabh Kumar | 41C | Deepti Singh Chauhan | 18C | Supriya Deshpande | 49C | Rajat Maloo | 37C |
INTRODUCTION
Medical tourism represents a worldwide, multibillion-dollar phenomenon that is expected to grow considerably in the next decade. During 21st century, India emerged as a favorable destination for obtaining medical services. This change was a result of overall development in technology, education and services due to which similar skills in medical professionals and services could be obtained in developing countries such as India at comparatively low prices. Internet acted as the biggest facilitator in this change. Not only doctors, but patients also took advantage of free flow of information about diseases and their cure. WTO also contributed significantly to the increase in trade of medical services under following 4 modes:- 1. Medical Travel – People travel abroad to obtain healthcare 2. Cross - border delivery of trade – Shipment of laboratory samples, diagnosis and clinical consultation 3. Setting up of health-care services overseas – Setting up hospitals, clinics and diagnostics center 4. Movement of health-care professional from one country to other – Movement of physicians, specialists overseas
The proportion of the elderly population is showing a progressive growth especially in the developed countries and with this trend the demand for healthcare facilities is likely to grow but the number of doctors in developed world is not keeping pace with the growing demand. This shows a significant growth market for the international medical services. The global medical travel market is estimated at US $30-40 billion which is likely to grow at 20 per cent. Major countries that are viewed favourably for international destinations for medical tourisms are India, Thailand, Jordan, Malaysia, South Africa and Cuba, with Thailand getting the largest market receiving patients majorly from USA and UK for dental treatment, cosmetic surgery, organ transplant and joint replacement. Major areas where people seek medical attention are Cardiac surgery, orthopaedic surgery, bariatric surgery etc.
The source countries are also promoting medical tourism since they also benefit in terms of employers’ and employees’ contribution to health plans and public health insurance systems by alleviating is waiting lists and saving financial costs estimated to about £200 million annually. By the enormous information available on the internet, the patients have become the decision makers. They decide what treatment they want, at what place and when and evaluate all their options based on price, quality, familiarity with the country, cost of travel etc. India has an edge over its competitors since around 20000 doctors pass out every year and the health care facilities provided are comparable to the best of the world at significantly low prices.
EMERGENCE OF INTERNATIONAL MEDICAL TOURISM
The present form of flow has been a completely different one, or can say is a reversal from the 20th century. Earlier there was a flow of patients from developing countries to developed countries, but now we see a movement from the developed world to the developing world, but with an increased focus on regional movements. The key factors include:
Regulatory- One of the reason for increase of international health care is that, technically it comes under the General Agreement on Trade and services under the auspices of WTO. It also has been facilitated by various bilateral and regional trade agreements. Healthcare is a service industry thus it causes health care services to be more tradable. And recently it has been facilitated by movement of patients across countries.
Cheaper access- These developing countries offer cheaper healthcare services in comparison to the developed world. For eg the below table shows the substantial differences in prices for different Services in the US and India.

Price comparison of different procedures for US and India (Source: OECD)
Enabling Infrastructure- The increased movement of patients has been facilitated by cheaper Air Tickets, readily available information, and decreased visa restrictions. The Internet has provided a platform for the various stakeholders to interact, and it also acts as a source of healthcare information. It also acts as a means for the various providers to advertise and attract their potential customers.
Industry Development/Expertise- In the recent years there has been rapid development in the healthcare industry in these developing countries through adaption of modern technology, education and training in modern sciences, this has has attracted more and more people from the developed world, and additionally these countries have also started focusing on medical tourism as an industry.

Some Other Factors
Development in Telecommunication: The development in telecommunication and other technological advancements in this filed has made it easy to communicate all around the world and has also facilitated services such as tele-consultation, tele-medicine.
Under capacity in Developed World- The number of old aged people is increasing and is set to increase in the future in the developed countries along with an increase in the average life expectancy which is leading to a demand which is not matching the number of doctors and nurses joining the medical workforce.

Source: Deloitte
Outsourced Patients- Patients who are outsourced by health agencies to other countries due to long waiting lists or lack of speciality equipment or personnel in the home country. Generally the patients are outsourced to relatively nearer countries. Eg of waiting list- UK, Eg of Lack of Speciality- Movement of patients from Bangladesh to India

Source: Deloitte
Travel Insurance- Emergence of travel insurance that covers both travel and international healthcare. It is easier for people with long history of ailments in the developed countries to get such insurances than their own countries
Development and Linkages- In some countries governments are looking to develop hospitals with a specific focus on regional medical tourism eg Apollo Hospital in Savita Vihar has an average occupancy of 30% of African Nationals. Increasingly hospitals are looking for international linkages to increase their recognition
National Strategies- Countries like Singapore have tied up with several players to promote themselves as Medical Hubs. India issues M Visa, allows tax breaks and incentives for providers etc.
Economic Factors- Changing economic factors, like recession may lead to decreased incomes, thus may force people to look elsewhere to save costs and reduce expenses during time of economic downturns.

ADVANTAGE INDIA!!
India has a strategic edge in following healthcare services: a) Cardiac Treatment
The cardiac treatment in India costs among the lowest in the world with the quality of treatment ranking amongst the best. India is a top destination for cardiac bypass surgery can cost less than $10,000 as compared to more than $100,000 in the west. According to the annual ranking of top medical tourism destinations published by the Medical Travel Quality Alliance, Asian Heart Institute, Mumbai ranks among the top ten medical destinations with the lowest surgical mortality rates in the world with 0.26% in isolated bypass surgeries & an overall mortality of 0.8%.

b) Orthopedic Treatment
Popular treatments sought in India include joint replacement surgeries such as hip grafting and replacement. Again quoted as one of the top ten medical destinations is the Fortis Hospital, formerly Wockhardt Hospital, which provides excellent surgery options for medical travelers seeking orthopedic procedures including hip resurfacing and replacement. It works closely with some US-based medical travel agents for follow up care and services of American patients once they return home.

c) Cosmetic Surgery
Breast enhancement in Britain will now set patients back by an additional US$1,500, jacking up the medical bill by an average 20 percent. In the Brit taxman’s lexicon, it is Value Added Tax, applicable on all cosmetic surgeries in that country. Such trends in developed countries have allowed India where such operations are still somewhat unregulated, much attractive. Cosmetic Surgery operations are largely concentrated in and around Mumbai. Most experts agree that the Indian cosmetic surgery sector is growing by between 20 and 30 percent

d) LASIK
Various hospitals in India provide the LASIK surgery operation at 25% the cost to US
Apart from these services, India has a strategic advantage in the following infrastructure facilities indicated by the number of JCI (Joint Commission International) accredited hospitals in the medical tourism destinations: Country | Hospitals | Cities | India | 21 (Fortis, Medanta, Apollo, Artemis, Aditya Birla Health Services etc.) | Delhi, Mumbai, Chennai, Pune, Kolkata, Hyderabad, Kochi etc. (Pan India) | Philippines | 6 (Chong, Makati, St. Lukes etc.) | Makati, Cebu, Taguig etc. | South Africa | 0 | Nil | Malaysia | 13 (KPJ Hospitals, Normah Medical Specialists etc.) | Kuala Lampur, Shah Alam | Singapore | 20 (Changi, John Hopkins, Parkway, National University Hospital etc.) | Singapore |
Source: http://www.jointcommissioninternational.org/about-jci/jci-accredited-organizations/
The high number of internationally accredited institutions provide larger choices for the incoming tourist/patient population
AN ANALYSIS OF MEDICAL TOURISM DESTINATIONS
The country-wise analysis is summarized in the table below: Country | Specialization | Strengths | Weaknesses | Recent Developments | India | Cardiac, Orthopedic, LASIK, Cosmetic Treatment | Low language barrier levels, Human Capital, Lowest Cost, High Quality | Low support infrastructure, Safety Concerns pertaining to crimes against women | Grant Thornton has predicted in November that Indian medical tourism industry will touch $8 billion by 2020 from its present value of $3 trillion | Thailand | Sex Assignment Surgery, Organ Transplants, Joint Transplants | Internationally acclaimed hospitals, Government-sponsored online marketing of medical services | Safety Concerns related to Insurgency | Ministry of Tourism has predicted that Thailand would see a loss of 1.33 million tourists and US$149 million due to reduced tourist confidence since the Erawan Shrine Blast | Singapore | Cardiology, Neurology, Oncology, Ophthalmology | Intensive network of accredited hospitals, Stable Political Situation | Lackadaisical promotion and a dearth of public health services | Many newspapers have reported that Singapore is pricing itself out of medical tourism due to rising costs | Malaysia | Cosmetic Surgery, Health Screenings | Affordable cost, Less waiting time, Political stability, | Low presence on Internet and lack of international accreditation | Malaysia, is set to earn around $220mn from medical tourism this year, after $191mn in 2014 | Brazil | Cosmetic Surgery | Large number (60+) of internationally accredited hospitals | Rising medical costs, Market duopoly in Hospitals causing large market power | Health insurance of expats made mandatory in Brazil prior to landing | Mexico | Cosmetic Surgery, Cancer Treatment, Dental Care | Low-Cost, Proximity to developed countries leads to higher travel volumes | Safety Concerns, Prevalence of duplicate and fake products causes issues | Medical tourism still growing under Obamacare where 80% of tourists cite low cost as the prime motive | Cuba | Neurological Disorders, Night Blindness, Cosmetic Surgery | Proximity to US and Japan, Low Cost | Restrictions and embargos placed over Cuba for years hampers its image | Doctors in Cuba have been flagged as high risk by US agencies for medical tourism, reported in WPost |

THE CHOICE OF THE TOURIST
In this new era, medical tourism has garnered great value. It may not limit itself to only health care services but in addition, have some other facilities like better accommodation, shopping and sometimes recreational arrangements. The major reasons for many people of developed countries opting for this new idea may include lengthy waiting time to get medical services or visa in some other developed countries, high expenses, and lack of medical insurance, or under-insurance. The avoidance of waiting times is the leading factor for medical tourism from the UK, whereas in the US, the main reason is cheaper prices abroad.
But still there are certain defining factors which the patients take into consideration before opting for the medical services from any location. These factors can be given as: 1. Cost: The complete costing that the medical service may demand is one of the major points that are considered by the consumers. Here, a medical service may include, actual price of the product, transportation or installation cost, physical cost or hard work to get that and social cost like getting appreciation or criticisms from others and opportunity costs to ignore other products. There can be some exceptional cases but cost affect tourist choice and satisfaction. Therefore, in medical tourism cost of medical service or fees, cost of accommodation, cost of food and transportation cost are vital issues for measuring the attractiveness of a destination. 2. Service Quality: The second most important factor is the service quality provided by the destination country in medical tourism industry. Medical tourists focus greatly on this issue. Thus the destination country must fulfill the expectations of the medical tourists through quality service and performance. This further can be segregated in 5 main divisions as in: a. Reliability b. Tangibles c. Empathy d. Responsiveness e. Assurance 3. Labor Force: Currently, this industry is facing serious concerns from consumers as they are demanding high level of excellent services and skilled labor. In medical tourism industry, customers evaluate quality based on the behavior and skills of the employees. Customers take the behavior of service providers as the key influencer in order to judge the nature of the service. Thus, there is a great correlation between customer satisfaction and employee performance that is well trained. Because of the variability in human beings, consistency of quality service is difficult to ensure. Accessibility: The country providing this service must be easily accessible from various parts of the world so as to have the ability to cover a large customer base. In addition the city and thus the hospital providing the medical services must be easily accessible from the major commercial cities of the country. This can be achieved by low cost airlines connecting the major cities with the cities providing medical tourism, special services provided for such patients etc. 4. Commercial Infrastructure and Environmental factors: Environmental factors play a major role in the decision making process when the patient is used to complete different surroundings and is new to the city they are opting for. Here, the surroundings will consist of the regular fauna and flora, climate etc of the city in question. Sometimes, the government’s policies are also taken into consideration . 5. Working History: The history of the country along with the opted hospital plays a defining part in this decision process. The image of the hospital should be clean devoid of any malpractices. The country must also show its intolerant behavior to any service provider violating the code of conduct.

Taking the above points into consideration, the weights to them can be given as 0.3, 0.2, 0.15, 0.15, 0.1, 0.1 respectively.
BIBLIOGRAPHY
http://www.shs-conferences.org/articles/shsconf/pdf/2014/09/shsconf_4ictr2014_01037.pdf http://www.beckershospitalreview.com/finance/why-are-more-americans-seeking-medical-care-in-mexico.html http://www.angeleshealth.com/the-only-10-countries-that-matter-for-medical-tourism/ http://hotair.com/archives/2015/02/20/shock-report-cuba-is-not-the-medical-paradise-advertised/ http://www.oecd.org/els/health-systems/48723982.pdf http://www.webster.ac.th/2012/pdf/thesis/2011-12/mba/Kristine%20Ricafort/RicafortK.pdf http://www.scirp.org/journal/PaperInformation.aspx?PaperID=7490 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4401052/ https://en.wikipedia.org/wiki/Medical_tourism