World Report
Medical tourism booms in India, but at what cost?
As India tries to position itself as a major player in global health care, how will its courtship of rich
foreign patients affect the care of India’s own people? Priya Shetty reports from Mumbai.
In a plush suburb of Mumbai in India,
a doorman guards the entrance of a
gleaming building. Inside, past the
marble floors, chandeliers, beauty
salon, and fine-dining restaurant, is an
elevator that takes the elite up to their
suites. Mumbai has its share of five-
star hotels, but this is not one of them.
It is the Kokilaben Dhirubhai Ambani
Hospital, one of the latest additions to
India’s increasing number of private
hospitals. These shiny symbols of the
country’s burgeoning economy have
been attracting increasing numbers
of medical tourists—patients from
other countries who come to India for
treatment that ranges from cataract
corrections to cardiac surgery.
The medical tourism industry is
growing fast, especially in emerging
markets like India. The Confederation
of Indian Industry predicts that India
will see revenues of US$2 billion from
medical tourism by 2012. Captivated
by this economic potential, the Indian
Government is actively courting
international patients. Yet despite the
industry’s predicted growth of 30% in
India, the country has not produced
any national medical guidelines on
this issue.
For doctors and ethicists, the lack of
regulation is ringing alarm bells. For one
thing, duty of care and accountability
are particularly murky issues in cross-
border health care. Additionally, Indian
doctors are concerned about the knock-
on effects of medical tourism on the
local health-care system.
Many private hospitals in India are
now seeking accreditation by the
Joint Commission International (JCI),
which has become a crucial stamp of
approval for hospitals in developing
countries seeking medical tourists.
The number of JCI-accredited foreign
medical sites worldwide tripled from
76 in 2005 to more than 220 in 2008.
www.thelancet.com Vol 376 August 28, 2010
The reasons why patients are willing
to travel long distances for surgery
tend to vary by region. In the USA, for
example, a lack of health insurance can
make treatment unaffordable (table).
In the UK, patients get frustrated with
long National Health Service waiting
lists and the high cost of private care.
Patients from the Middle East and
Africa are drawn to India because the
technology or medical expertise is
lacking in their own countries.
“For doctors and ethicists, the
lack of regulation is ringing
alarm bells.”
The Indian Government, eager to
expand its economy, has begun to
aggressively court foreign patients
through tourism campaigns that
sell a unique mix of cutting-edge
technology with ancient medical
traditions in the form of ayurveda and
yoga. The government has also created
a special medical visa that lasts up to
1 year to make it easier for patients to
enter the country. The result of this
government cooperation has been an
extraordinary expansion of corporate-
owned hospitals across the country.
Kokilaben is only 18-months old, but
other private chains such as the Fortis
Hospitals group, known for specialties
such as cardiology, have been around
for several years. Fortis Chief Executive
Officer Vishal Bali says that the chain of
48 hospitals across India was built in
less than a decade.
Although the American Medical
Association, for example, issued
guidelines on medical tourism in
2008, India has so far chosen to leave
it to private institutes such as Fortis
to make their own rules. This June,
researchers concerned about the
ethics of such self-regulation met at
a conference on medical tourism held
by Simon Fraser University (SFU) in
Vancouver, Canada.
Valorie Crooks, who studies health
services research at SFU organised
the conference with Jeremy Snyder, a
health ethicist at the university. Crooks
says that medical liability is a serious
concern. “In societies that are litigious
in nature, such as the US, there is a
concern that physicians will not want
to provide follow-up care for patients
treated abroad in case complications
arise”, said Crooks. “There are no
formal legal frameworks to protect
international patients seeking medical
care abroad”, agrees Indrajit Hazarika,
who researches health-system streng-
thening at the Indian Institute of Public
Health, Delhi. “In the event that some
medical malpractice error does occur,
it is very unlikely that the patient will
receive any financial recourse in the
foreign country”, he adds.
Suresh Rao, a paediatric cardiologist
at Kokilaben hospital, estimates that
about 15% of his patients come from
abroad. Rao admits that the contract
that patients sign with the hospital does
not oblige him to provide aftercare.
“If there is some issue, they will have
to get seen by their home physicians”,
he told The Lancet. Nevertheless, he
says that he and other doctors at the
hospital keep in touch with patients via
email or phone because they view good
follow-up as their moral responsibility.
Vishal Bali says that doctors at Fortis
also work hard to maintain links with
patients after treatment, and the
hospital chain has even subsidised the
air fare for patients who have needed
to return for follow-up treatment.
“We don’t at any point in time want to
give an indication to our international
patients that after the procedure we are
not interested in their care.”
So far, there have been no major
reports of such hospitals, in India at
671
 World Report
USA
Angioplasty 98 618
Heart bypass 210 842
Single heart-valve 274 395
replacement
Hip replacement 75 399
Knee replacement 69 991
Gastric bypass 82 646
Spinal fusion 108 127
Mastectomy 40 832
Costs of procedures (US$) in the USA (retail rather
than insurers’ cost) and India, 2006. Source:
Subimo (US rates), and PlanetHospital (India rates).
Table: When the price is right
least, abandoning follow-up care. The
competitive market-driven nature of
the industry acts as an incentive for
hospitals to ensure that patients are
happy with their aftercare—hospital
administrators say that many people
use word-of-mouth recommendations.
Bali says that Fortis safeguards both
itself and patients by avoiding travel
or tourism companies that do not
have medical advisers. “All our health-
care facilitators must understand the
seriousness of medicine.”
In some ways, health insurance
companies offer patients protection
by vetting hospitals first. Mihir Bapat,
a spine surgeon at Kokilaben, says that
his international patients’ insurance
companies are “particularly careful in
sanctioning treatment. They ask a lot
of questions”.
However, Vivek Jawali, chief
cardiothoracic surgeon at Fortis
Hospitals, says that although Indian
hospitals are behaving responsibly for
now, “national guidance will come; it
must”. Bapat is also strongly in favour
of better national guidance. “Medical
tourism is active but there are no
laws per se as to how an institution
manages it”. The guidance is crucial,
he says, because in interactions with
international patients “there can be
language barriers, sociocultural barriers,
and you need to understand those
barriers to treat these patients.”
But ethicists are not just concerned
about international patients. In-
creasingly, Indian doctors are worried
672
India about how gearing the health care
11 000
system towards rich foreign patients
10 000
will affect the care of India’s millions of
9500
impoverished people. George Thomas,
chief orthopaedic surgeon at St
9000 Isabel’s Hospital in Chennai, India, and
8500 editor of the Indian Journal of Medical
11 000 Ethics, spoke at the SFU conference in
5500 Vancouver. Thomas told The Lancet that
16 833 hospitals designed to attract medical
tourists have been built “by lobbying
the government for cheap land to
build the hospital, cheap loans to
finance expenditure, and tax breaks. In
a country, where the poorest are taxed
on every item they buy, the concessions
handed out to the rich are simply
obscene.” Not only that, many hospitals
are ignoring the responsibilities that
such concessions come with, says
Sunita Reddy, at the centre for social
medicine and community health in
Jawaharlal Nehru University in Delhi,
who has co-authored a review of the
effect of medical tourism on local
health care.
A 2005 report by the Indian
Government’s public accounts
committee investigated whether
private hospitals in Delhi had kept their
promise of providing some free health
care in return for being sold land at
hugely subsidised rates. Subsidised
hospitals were asked to provide free
care for 25% of inpatients and 40% of
outpatients, explains Reddy. But the
report concluded that most institutions
had not offered this care. “The policy
could have provided life-saving
opportunities to some of those who are
afflicted with complicated and deadly
diseases but [who cannot afford] costly
medical treatment”, says the report.
“What started with a grand idea of
benefiting the poor turned out to be a
hunting ground for the rich in the garb
of public charitable institutions.”
These criticisms are particularly
important since India is trying to
position itself as a key player in global
health care. Crooks notes that “these
countries are buying into the WHO’s
focus on renewing the commitments
to primary health care made at Alma
Ata, but instead we see these public
dollars being shifted into private health
care and the benefits for the public are
really unclear.” Private hospitals are
defensive about these criticisms. Bali
says, for instance, that international
patients tend to use high-end hospital
suites “that would only be used by
15–20% of the Indian population any-
way”. An average 10-min outpatient
consultation in a private hospital in
India costs between Rs500 and Rs1000.
For many Indians, this would be half
or more of their monthly salary. But
Bali says that poorer sections of the
population can still access care through
government insurance policies.
Although claims that hospitals are
reneging on promises to provide free
care do seem to have some evidence
behind them, researchers say the lack
of data for the ethical fallout of medical
tourism is a serious issue. “Countries
that see medical tourism as a solution
to development of their health-care
centres should be cautious”, says
Snyder, ”because there are a lot of
anecdotal stories about how medical
tourism can harm health inequity, but
without better data it’s hard to make
the argument that that’s always the
case or even often the case”.
Hazarika believes that there are
genuine ethical concerns, but agrees
with Snyder that “almost all the pub-
lished reports on this issue are based
on speculations and assumptions”. As
well as better ethical guidelines, it is
clear that India also needs government
support to document the effects of
medical tourism.
Outside Kokilaben’s gleaming air-
conditioned walls, meanwhile, the
chaotic reality of India, and the gap
between rich and poor, has never
been more evident. A sleek black car
delivering a patient to the hospital
speeds through a monsoon-flooded
road, splashing a rag-clad beggar in the
process. Used to the inequity of life in
his country, he simply shakes himself
off, shrugs, and moves to a drier spot.
Priya Shetty
www.thelancet.com Vol 376 August 28, 2010