380-404 Annamalai Murugan

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Medical Tourism: Opportunities and Challenges in Tamil Nadu Dr. Annamalai Murugan* Introduction 1.1. Where does India Healthcare Industry Stand? India has a wide network of public and private hospitals; most of the healthcare services are provided by the private sector. Public sector institutions are run by the Central or State government bodies, whereas private hospitals are managed by trusts as a profit or not-for-profit organisation. In the recent past, there have been major changes in healthcare delivery. India is gradually moving from conventional standalone set-ups to hospitals chains with well integrated networks. There is increasing penetration of Information Technology (IT) applications in healthcare institution. An It Application further enhances the quality of care and helps to provide one-stop-solution to the patients need. India is also at the forefront to adopt innovative solutions such as usage of telemedicine services. There is a continuous increase in the number of healthcare institutions offering telemedicine services. Telemedicine infancy, but it is making intrados at a fast and peace India is expected to emerge as a country with a high penetration rate for telemedicine. 1.2. Healthcare delivery in India-a snapshot India needs to expand its healthcare facilities to cater to its one billion plus population. India has around 180,000 hospitals out of which 1,60,000 are primary healthcare centres. India has a three tier system. Tier 1 hospitals provide super speciality healthcare services, for example, Cardiac surgery, Surgery Tumour Removal, Organ Transplantation etc. They are located in metros and state capitals, around 70-80 per cent of tier 1 hospitals have around 250-300 beds. Tier II hospitals are general hospitals, which do not conduct super-specialty surgeries. They are mainly present in State Capitals and other important cities in each state where there is negligible presence of tier I hospitals. Tier II hospitals typically have a bed strength ranging anywhere between 50-100 beds. Tier III is generally 5-25 bed hospitals which are more popularly termed as nursing homes in India. They may have a small ICU with very basic instruments and a minor OT attached for very basic procedures. In big cities, they play a primary role in treating patients with minor ailments, which do not need surgical intervention or advanced care. Conversely, in small towns they perform the same roles , which tier II hospitals perform in the bigger towns and cities, namely, to stabilise patients with serious conditions and then transfer them to tier I hospitals for advanced treatment. Health services will also have to cope with an increase in the chronic and lifestyle-related conditions associated with rising incomes and greater longevity. In India, 80-85 per cent of the health care expenditure is borne by the patient; 12-15 per cent by the government and a mere 2-3 per cent by the insurance sector. Due to inadequate support from the government, the Indian market is completely controlled by the private sector marking it very price sensitive. This year, the governments budgetary allocations to healthcare have also been increased to 21.9 per cent over the previous year. The per capita expenditure on healthcare is also on the rise due to the increase in related diseases. To cater to this demand, both public and private healthcare facilities are working towards efficient, affordable and quality healthcare delivery. The private sector is focussing more on tertiary level healthcare services whereas the government is concentrating on the root causes through services towards prevention and eradication Physical Infrastructure (Investments) The Indian healthcare delivery market is also making its presence felt in the global market by providing high class quality services and focussing on medical tourism. An estimated 50 per cent of tertiary level hospitals focus on providing services to the medical tourism sector. Some big industry players like Apollo, wockhardt; Max, Fortis, Manipal, etc. have changed the face of the industry by providing world-class healthcare facilities. They already have hospital chains covering all geographic regions of India. Nevertheless, the current healthcare infrastructure in India is inadequate to meet the future needs. An estimated 7.5-9 lakh hospital beds are required by 2012 to meet the current rate of demand. This infrastructure would need an investment of approximately US$30-40 million.
*Lecturer in Tourism Management, Tagore Government Arts College, Pondicherry. murugan_33@hotmail.com
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IIMK Part IX Medical Tourism IIML
77,962
38,824
7,828
2006
2009
2012
Source : Emst & Young Report: Cumulative investments
To meet this demand, a new paradigm in healthcare is the concept of Health City- Township with integrated healthcare facilities. By 2010, about 10-12 health city projects will start operations across India. Health insurance medical tourism and corporate hospitals have resulted in higher demand of quality services. This has resulted in the formation of regulatory and accreditation bodies to define standards and regulations for various healthcare facilities. This initiative will definitely improve the quality of services provided by the Indian healthcare industry. Medical Equipment Market
4,978
3,275 2,177
2006
2009
2012
Source : Ernst & Young Report
Many major hospitals like Apollo and Wockhardt have already achieved the highest level of quality certification from JCI (Joint Commission International) for their healthcare services. 1.3. Leading diseases The leading diseases of the country are Asthma, cardiovascular disease, Tuberculosis, Cancer, Diabetes and AIDS. Urbanisation air pollution and environmental tobacco are the prime reasons for the increase in the prevalence of asthma. Around 20 million people in India are suffering from asthma; majority being children. Early exposure to chemicals, pesticides and smoke are the prime reasons for increased incidence of asthma in children. India is trying to control the prevalence of asthma by strictly prohibiting child labour, as this is also one of the major reasons owing to which, children are exposed to chemicals and pesticides. Health Service Outsourcing Cardiovascular disease is the killer disease in the whole world. India with around 35 million has the highest number of people suffering from cardiovascular diseases in the world. There is a dramatic increase in the incidence of chronic illness would be in the cardiovascular area.
Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK
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Tuberculosis kills almost 1,000 people everyday; Tuberculosis morbidity varies between 0.7-3.7 per cent in different areas. The major factors that influence the prevalence of tuberculosis are nutrition, housing, industrialisation and urbanisation.
7,400
3,700
2006
2012
Source : Emst & Young Report: Cumulative investments
The number of Indians suffering from diabetes currently is around 35 million. Every year about 1.1 million new diabetic cases are added to the 35 million. It is expected that by 2020, every 5th Indian would be a diabetic.
Making Room The major healthcare chains are on an expansion spree. APOLLO HOSPITALS: Has 41 hospitals offering 7,228 beds. By 2010, it expects to have 12,000 beds. FORTIS HEALTHCARE : has 12 hospitals with 1,900 beds and has plans of going up to 40 hospitals and 8,000 beds by 2010 WOCKHARDT HOSPITALS: It plans to double the number of hospitals to 14 by 2008 and take the cumulative bed capacity to 3,000 from 1,500 at the moment CARE HOSPITAL: Has eight hospitals with 1,000 beds and plans to add 5,000 beds in the next five years (1,000 each year or six to seven hospitals each year), taking the total number of hospitals to close to 40 in five years. MAX HEALTHCARE: Has seven hospitals with 800 beds and by 2010, will have 11 hospitals and 1,500 beds. PRIVATE EQUITY AND HEALTHCARE Global investors are betting on the Indian healthcare market. George Soros Quantum and Blue Ridge funds bough around 7 per cent stake in Fortis Healthcare for $33 million (Rs 145.2 crore) in 2006. IDFC Private equity put in $20 million into Manipal Health Systems in 2006 IDFC Private Equity also invested $10 million in Bangalore based Healthcare global Enterprises in 2006. ICICI Ventures India Advantage Fund-I paid $8 million to acquire around 18 per cent stake in Metropolis Health Services, Indias leading corporate diagnostics chain, in 2006.
1.4. Healthcare in South Region Since the last few years the south region of India has shown improved health indicators and has become tech-savvy, but there are loopholes that still need to be mending. The land of elephants, coconuts and coffee south India a linguistic cultural region of India comprising the four states of Andhra Pradesh, Karnataka, Kerala and Tamil Nadu and the union territory of Pondicherry, is today the home of hi-end technology in healthcare. The region boasts large number of multi and super speciality hospitals; highly qualified and experienced doctors best teaching institutes and excellent services and facilities which have further led to high focus on technology up gradation and rationalisation of cost.
Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK 382
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In the social sectors of health, the region has taken some impressive strides. Tamil Nadu has seen improved life expectancy at birth (LEB) rate, whereas LEB of Kerala males has increased to 70.4 years in the year 1995, an increase of 26.1 years in a span of 40 years. This has been largely due to low infant and child mortality, particularly for males (HDR 2005). According to the HDR 1999, LEB in Karnataka for males has also improved to 60.6 years and that for females 63.9 years. Kerala and Pondicherry has shown an overall better crude death rate (CDR) in the region- 6.3 per 1,000 populations in 2003, however the state of Karnataka claims highest birth rate in the region 21.8 in 2003. The state of Andhra Pradesh shown appalling figures of infant mortality rate (IMR) around 59 per 1,000 populations for the year 2003. Also all states of south India have shown a rapid decline in the total fertility rates (TFR). By and large the health indicators have improved in the region attributing the credit to progressive socio-cultural movements, sustained information programmes education, rising aspirations, better health as well as improved literacy levels. Besides the improvement in health indicators healthcare in south India has developed due to the procurement of hi-end equipments and also due to the multi-disciplinary approach towards treatment. Every States in south has an expanse of health services spread across the region. This has been witnessed in non-government organisations, where there has been a significant proliferation of corporate, small private hospitals and non-profit hospitals. The major factors that have prompted this stark improvement is the demand, poor or no services in the government sector, population growth, better economic conditions and greater awareness among people. 1.5. Healthcare structure The healthcare delivery system in South India is structured mainly on the basis of national norms, aiming to integrate promotive, preventive and curative aspects. The Directorate of Health and Family Welfare Services is mainly responsible for the provision to health services. The medical college run by the state and government hospitals attached to teaching institutions, including private medical college, nursing colleges and nursing schools come under the jurisdiction of the Director of Medical Education. Typically, there are hospitals at district and sub-district level, whereas primary health centres (PHCs); community health centres (CHCs), sub-centres and trained dais are prominent in the rural areas. The highest number of PHCs functioning as of September 2005 in the south region is in the state of Karnataka1,681 and the least are in Kerala-911. According to the HDR 2003, PHCs cater to a larger section of the rural population in Tamil Nadu and almost 35 million out patients are treated in PHCs annually. In the rural region, the number of district hospitals is high. In fact in Andhra Pradesh the intensity of healthcare has proliferated in rural areas whereas missionary institutions are high in Kerala. Though there is large number of government hospitals, inadequate services have given a way to the rise in private sector. The expansion of the private sector, however, has led to an increased inequality in access to health services. The poor and underprivileged cannot afford the costs of the private hospitals so the issue of class, caste and gender needs to be talked in a multi dimensional approach. Leading diseases Infant mortality is a serious issue in south India; major causes being inadequate antenatal care and maternal malnutrition. Lack of essential and emergency obstetric care, proper health facilities, poor nutrition, increasing anaemia cases and enormous burden of hardwork has added to the high rate of maternal deaths. Inadequate nutrition levels have also affected the health of mothers and children leading to disease and infection. Despite a successful immunisation programme in Tamil Nadu compared to 15 major Indian states the nutritional status of children is still a matter of serious concern. Besides nutrition, AIDS cases are escalating in south region; Tamil Nadu also has estimated around 300, 0000-3500, 000 HIV positive cases. Pollution has become one of the leading reasons for increasing respiratory infectious diseases. Among the chronic illness, cardiovascular diseases. Among the chronic illness, cardiovascular diseases, cancer, hypertension, diabetes, etc. are emerging a the severe health problems of the region owing to sedentary lifestyle, lack of physical activities and obesity Ageing is another area of concern accounting for the overall hike in morbidity of the region. The morbidity analysis of the state of Kerala reveals acute diarrhoeal diseases, measles, pneumonia, pulmonary tuberculosis, dengue, etc to be the dominating ones. Also with rainy seasons, communicable
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diseases began to dominate, for instance the attack and death de to chikungunya that affected around 42,750 and resulted in the death of 75 persons in Kerala. Establishment of Primary Health Centres during Five Years Plans
1800 1600 1400 1200 1000 800 600 400 200 0
Po nd ich er ry Pr ad es h Ka rn at ak a Ke ra la il N ad u
Sixth Plan (1981-1985) Seventh Plan (1985-1990) Eighth Plan (1992-1995) Ninth Plan (1997-2002) Tenth Plan Target (1997-2002) Functioning as on Sept 2005
An dh r
Source: Modern Medicare March 2007.
2.1. Technology and achievements Pacing with the changed times, south India has always been on the forefront to provide hi-end treatment by the means of sophisticated medical technology. Incorporated largely by private hospitals, this new generation technology has become the integral part of the region. To cite a few examples, the state of Karnataka was the first to introduce micro-insurance facilities for its population and was also the first to introduce telemedicine facility with ISRO. Institutions like Manipal Health Systems. Wockhardt Heart Centre. MS Ramaiah Hospital, Sri Sathya Sai Institute of Medical Sciences, Narayana Hrudalaya and many others has given a revamped look to the healthcare delivery system of the state of Karnataka. Hospitals like Columbia Asia based in Bangalore, is the first to enter the healthcare industry in India through the FDI route. Our model hospital delivers a more tightly defined set of products and services as compared to traditional hospitals. This model has proven successful in Malaysia. Equipped with latest medical devices to offer internationally proven trends in medical procedures and healthcare, Columbia Asia uses unique proprietary operating software to maintain all patient records electronically and the OTs conform to ASHRa (American Society for Heating and Refrigeration) standards. Individual achievements have been equally fabulous in the state. Manipal Hospital was the first in the country to receive ISO certification and Golden Peacock Award. It is also the first in the country to provide heli-ambulance service with a DGCA approved helipad within premises. Manipals laboratory is the first one to be accredited by NABL and has the first JCMR approved and DBT authorised trials on Stem Cell therapy in the country. It is also amongst the first three hospitals in the world to introduce techniques like ROLL (Radio Occult Lesion Localisation-for breast cancers) and RGNS (Radio Guided Neuro Surgery for bran tumours). In the state of Andhra Pradesh hospitals like Global Hospital, L V Prasad Eye Institute, Usha Mullapudi Cardiac Centre, Apollo Hospitals, Asian Institute of Gastroenterology, have set a benchmark with advanced treatment modes. LV Prasad Eye Institute is one of the comprehensive eye care centre in India and the first institute in the world to reach an annual figure of 1,000 corneal transplants/year. It had done the highest number of stem cell transplants in the world and is also the first in the world to have an integrated secondary and primary eye care network in rural areas. The state of Tamil Nadu also boasts of multi and super speciality that are run on professional lines with all equipments conforming to international standards, like KG Hospital, Apollo Hospital, Sankara Nethrayala, Cancer Institute Adayar, Dr. Agarwals Eye Hospital, MIOT Hospital, Sri Ramachandra Medical College,
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etc. KG Hospital based in Coimbatore has performed Indias first Awake Open Heart Surgery and has also dialysed a tow-day-old baby. It had performed multi organ transplants by harvesting the liver, eyes and kidneys to different people from a brain dead victim-first in the region. A record of its kind was correction of five heart defects in a 5-year old girl. Dr. Agarwals Eye Hospital is known for introducing revolutionary techniques in eye care like 0.7 mm sub 1mm cataract, phakic IOL, multifocal IOL. Aberration frees IOL, presbyopic LASIK, conductive keratoplasty and many others. The institute has also received ADCRS video award for the 0.7 mm phakonit cataract surgery, ECRs Dr. Kelman Award and Barraquer Award. Most of the medical institute in Kerala are renowned to cater the foreign tourists. With the blend of auyrveda, spas, diversity of places to visit and lastly state-of-the-art healthcare delivery, the state gets patients from across the world. Kerala Institute of Medical Sciences, Christian Medical College, Meenakshi Mission Hospital and Research Centre, Thiruvananthapuram Medical College, JIPMER, are few hospitals catering to the population. 2.2. Medical education and research Medical education in India is based largely on the western model and unfortunately the curricula fail to match local health needs. Thus products of such a system are mismatched with the existing expectations. For effective and efficient healthcare delivery in rural and urban areas, adequate training facilities should be made available for medical and paramedical workers. With highest number of medical colleges and research institutes, the south region has become the hub for the same in the entire nation. The state of Karnataka has 33 medical colleges-the largest in the nation, while the other states follow in research especially. In the last five years ground-breaking research has been witnessed in south India. L V Prasad eye Hospital has explored the areas of molecular genetics of the eye, stem cell biology, infections clinical trials epidemiology, health economics and operations research. Similarly, Dr Agarwals Hospital has been involved in the research in diabetic retinopathy, stem cell, aberropia, myopia in children and many others. Manipal hospital has worked in the forefront of tropical diseases, anaesthesiology, anatomy, diabetes, cancers and neurology. Our stem cell unit has now moved from basic science research to trials and will offer therapy ff the shelf in the near future KG hospital on the other hand, has planned to establish a Stem Cell Research Centre in collaboration with Reliance Life Sciences. 2.3. Government aid The most common question raised is- with0.8 per cent of GDP allotted where do you expect to pour more resources? The government support isnt much impressive in the region, ruling out few generous initiatives. For instance the Tamil Nadu Government is involved in blindness control and Vision 20/20. Also, the Karnataka government has been proactive in supporting the healthcare infrastructure in the state and was amongst the first in the country to encourage the private sector participating in healthcare delivery. The other recent endeavours like purchase of CT and MRI machines for all district hospitals and connecting them to nearest super speciality hospitals has been a positive move by the Karnataka government. Governments focus has always been to ensure, fair distribution of financial costs for access and training providers for competence, empathy and accountability and special attention to vulnerable groups such as children women disabled and the aged. Besides policy and regulatory issues, the department of health in Karnataka has been in touch with the private healthcare providers to introduce new and innovative centres of excellence. In some states, the government has been very proactive in managing epidemic outbreaks. However in other states despite the attempts government is not in a position to combat epidemics that create panic from time to time, especially in cases like dengue fever. As a result private hospitals have taken the charge along with voluntary organisations in handling mass causalities during epidemics and natural disasters. 2.4. Rural healthcare status The rural healthcare needs tremendous support from the government. Currently the lack of basic infrastructure in the interiors is responsible for the hike in illness prevalence rate, especially in Kerala. Similarly, the health budget of the government of Kerala is very fragile in terms of allocation for medicine and supplies. The government also lacks in monitoring maternal mortality and morbidity rates.
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Owing to non-availability of infrastructure and facilities, like school, colleges and housing, doctors still find it difficult to migrate to rural areas for practice. Thus doctors by and large do not venture out in villages to provide healthcare to the poor in a greater measure.
Estimates of Birth Rates and Death Rates -2003 Birth Rate Rural Urban Total Rural 20.9 19.1 20.4 8.8 23.2 18.6 21.8 7.8 16.9 16 16.7 6.4 18.8 17.3 18.3 8.5 18 17.5 17.5 7.7
State/UT Andhra Pradesh Karnataka Kerala Tamil Nadu Pondicherry
Death Rate Urban 5.4 5.6 6.1 5.6 5.4
Total 8 7.2 6.3 7.6 6.3
Fortunately the involvement of private and corporate hospitals in improving the rural healthcare scenario has given a ray of hope. Manipal group has adopted 11 villages, treated over 50,000 people and holds 23 weakly clinics. It has achieved success with 91 per cent infant immunisation cover, 91 per cent female literacy and low death rates/low infant mortality rates. Under the eye research centre, a unit of Dr. Agarwals Eye Hospitals, more than 100 patients from rural areas are operated absolutely free every month. The hospitals also organises free eye camps and free OPD on the last Sunday of every month. Many hospitals along with the Rotary Foundation are undertaking path breaking research projects and national health programmes in the villages. Besides Anganwadi workers also play a major role in providing thrust to the primary healthcare scenario. 2.5. Medical insurance Medical insurance in general is gaining importance and is popular with people from all sections of society. The concept is yet to take shape and about 10 per cent of the population has medical insurance, which is a much better figure, compared to last five years. Micro-insurance has been introduced in this region and the government is planning to introduce similar scheme through schools and post offices however, there is a dire need of awareness about the subject among the poor classes of the region. The Manipal Groups Manipal Arogya Suraksha Scheme covers over 80,000 lives in association with ICICI Lombard. It has distributed over 25,000 green cards in the slums across Bangalore districts that enable free consultation and treatment and provide drugs at discounted price. Columbia Asia wills soon set-up a Customer Guidance Cell to educate people about the benefit of health insurance. State/UT Andhra Pradesh Karnataka Kerala Tamil Nadu Pondicherry Medical tourism Here, Bangalore and the state of Kerala score high-the former because of its international nature and connectivity and the latter because of ayurveda and spas. However, many private and corporate hospitals are currently catering to the needs of foreign patients. Better travelling modes, tie-up with five star hotels travel agencies and international government agencies, etc., a few of the development in promoting medical tourism. Manipal Group has a tie-up with some foreign governments like the Government of Tanzania, Government of Mauritius informal relations with Maldives, etc.; Dr. Agarwals Eye hospital receives patients from almost all Asian countries. Being cost effective with state-of-the-art infrastructure, the hospitals now receive patients from the UK and US. In fact, ophthalmologists from around the world have started visiting Dr. Agarwals Eye hospital to learn techniques invented by the hospital.
Infant Mortality Rates - 2003 Infant Mortality Rate Rural Urban 67 33 61 24 12 10 48 31 33 17
Total 59 52 11 43 24
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Eventually the government in this region is supporting the private hospitals by the means of developing infrastructure. For instance, Karnataka will soon get an international airport in Danhalli, which is claimed to be the largest such in south Asia. This will enhance connectivity with almost all countries in the world. However, the struggle is still on, to improve infrastructure in terms of quick evacuation and pick-up and drops facility from hospital to the airports; more five star hotels and beautification of existing tourist places. 3.1. Things to do The government needs to play a strong role in providing quality healthcare to the masses. According to HDR 2003, the Tamil Nadu government should bring down the TFR to 1.5 by 2010; should cut down the IMR to at least 30 by 2010 should raise life expectancy to 75 years by the next decade; should reduce the maternal mortality rate to less than one by the end of the next decade; should undertake close study and remedial measures to reduce the incidence of diseases; should eradicate vector borne diseases like malaria and filarial water borne disease like hepatitis and communicable diseases like TB and should improve overall health by reducing rural and urban poverty and provide sanitation facilities through more effective resource allocation. HDR 1999 suggested for the state of Kerala that a judicious combination of incentives and deterrents must be worked out to draw public and private medical personnel into poorly served districts. To improve the face of rural healthcare in the south region, more medicines and supplies needs to be provided to the government hospitals and health centres and for this, budget allocation should be augmented, changes in approach are also required in reaching the health. Sanitation and nutritional message to the farthest corners of the state. Bali elaborates; Government needs to start some kind of disease mapping system. For instance, child obesity is increasing but is it region specific? Facts like these are not available. Once disease mapping is made available it will be a boon for next generation, as it will help the industry to understand its diagnosis and treatment. With the R&D point of view, medical colleges and pharma companies should work in collaboration along with the need for basic privatisation in some areas of healthcare delivery. Health being a state issue one of the biggest platforms to be looked at is the public private partnership (PPP), which will create viability participating in paramedics, teaching research, etc., 3.2. In the coming years The years ahead will sea a rapid growth in the number of world-class facilities offering entire gamut of procedures. A greater number of people utilising health insurance will be seen along with the reduction in the number of smaller level facilities. The future will see more corporate hospitals, with more technology dependant care. Most hospitals are likely to get accredited, thus benchmarks will be created in healthcare to attract foreign patients to come to India for treatment. Doctors in this region holding great esteem abroad will perform high number of breakthrough surgeries for complex problems. Soon, a large number of Indian doctors will go abroad in a greater measure to train foreign doctors.
State/UT Andhra Pradesh Karnataka Kerala Tamil Nadu Pondicherry Number of Sub-centres, PHCs & CHCs Functioning Sub-Centre PHCs 12522 1570 8143 1681 5094 911 8682 1380 76 39 CHCs 164 254 106 35 4
A foray in private equity, ventures, especially by private players will be a step forward. The current private and corporate players have chalked out their expansion plans to establish more hospitals across the nation and smaller centres in the interiors. Theses hospitals will initiate preventive programmes for people through promotions and tie-ups with large institutions. With the vision of Health for All the days ahead will witness healthy competition between healthcare providers in South India that will lead in the outcome of quality and better healthcare. 3.3. Indian Dental Industry - an Overview Over the last five decades, patients with oral diseases such as dental caries, gum disease (periodontics), malocclusion and oral cancer have been increasing in India This is due to changing lifestyles including
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diets rich in sugar, increasing consumption of fast food or refined foods, poor oral hygiene, consumption of tobacco in many forms like betel nuts quid and pan masala and increased consumption of alcohol. Other reasons include lack of knowledge or education about dental problems and presence of high fluoride in drinking water in many areas in India. Majority of population is below the poverty line and cannot afford expensive dental check-ups and treatments. To add to this, the Government of India does not spend much on the dental sector, as it does not consider it a high priority sector. Most of the dental expenses are borne directly by the patient and only about one per cent of the Indian population has individual health insurance coverage. Also the government decision-making bodies in India lack dental health planers with relevant qualification and training Therefore, this industry is solely driven by and dependent upon the medical professionals. India currently has an estimated 80,000 dentists and the dentist to population ratio is still 1:22,500 which is critically low when compared to the recommended 1:7,500 dentists to population ratio by the WHO. Nearly 72.2 per cent of the total population lives in the rural areas and almost all of them are deprived or are unawareness of basic dental care or dental facilities and services. In Western countries, incidence of dental diseases has been brought down markedly by oral health education, modification of diet and use of fluorides. Despite the market a sizable opportunity for growth of the dental sector in India that needs to be explored. India has an estimated 100-150 million disposable income population who have capability to spend for private healthcare services and this population is growing at a rapid pace Constituting about 10-15 per cent of Indias total population, the growing middle income group are seeking international quality medical services in super-speciality hospitals, thereby dividing the growth in the Indian dental sector. As the population has become more affluent and educated, the value placed on oral health has increased. In addition, the desire for aesthetic dentistry has grown and will probably continue to do so. Advent of cosmetic dentistry focusing on improving the appearance of oral cavity and use of advanced technology like laser, digital radiography and CAD/CAM systems has increased the demand. Though majority of the population still lacks awareness on oral dental hygiene, efforts from the Indian Dental Association (IDA) coupled with technical and financial support from private companies like Colgate Palmolive (India) Limited in launching an intensive awareness and education campaign has tremendously helped increase oral health care education and regular dental check-ups. Organisations like Dental Council of India (DCI) and Indian Dental Association (IDA) are instrumental in regulating standard in the dental practice and maintain code of ethics in the dental profession. DCI regulates dental education; the IDA was instrumental in bringing out National Oral Health Policy and has been the leading authority in the Indian oral health sector. This is one of the largest recognised bodies of dental professionals in India. Due to the diversity of medical practice in India, there are several laws relating to the various system of medicine, which attempt to maintain a central register of qualified practioners. The Dentists Act of 1948 (http://disc.iisc.ernet.in/vigyan/dent.html) controls the practice of dentistry in India. From the standpoint of companies who would like to enter this market. There is huge opportunity awaiting them mainly due to high prevalence of dental disease patterns in India. They need to give attention on educating patients on importance of dental screening and how the emerging new technologies have potential to make a positive impact on quality of life of people. Though Government of India does not spend much on the dental sector, it has liberalised the trade unions and made the customs duty on the dental imports almost nil, which has opened up opportunities for tremendous growth. About 40 per cent of the Dental Equipment (DE) and consumables in India are estimated to be imported every year. The adjoining chart depicts the imports and exports of DE and supplies. They are estimated to grow at the rate of 18 per cent annually as shown in the figure. Imports by hospitals include dental cements and specialty dental fillings, dental instruments and appliances, dental chairs and furniture drill engines and artificial teeth. New approaches of dental treatments have changed the perfunctory way of looking at dental care. Cosmetic dentistry is a new branch of dentistry which focuses on modification of appearance of a patients oral cavity and surrounding and thereby improving the appearance of a persons teeth, mouth, and smile. Several major hospitals across India are now offering the latest dental treatment at very competitive prices. The Government has started realising the export potential of the dental services sector and is now planning to provide incentives to boost dental tourism. Cosmetic dentistry procedures like smile designing, metal free bridge, dental implants, porcelain metal bridge and crown root canal treatment complete dentures, and dental veneers among others are done at extremely lower prices (of almost 70 per cent less than the Western counterparts) with an uncompromising
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level of international quality treatment. This has made India a favourite hot spot example same designing costs about $1,500 at a top end dentist in India as against $8,000 in the US and dental implants that cost $3,500 in the US are only close to $1,000 in India. High incidence of oral diseases coupled with efforts by WHO and other private organisations to increase awareness of dental hygiene is going to tremendously increase demand for dental care, facilities and services in future. The current government is dedicated to opening India up to the world. Incentives given by government like liberalisation of trade unions and almost zero import duties have potential to attract huge investments in Indian dental industry. 3.4. Indian Tourism- On the Upswing International Recognition Along with the growth of this industry, international accolades have been pouring in, rising India's appeal as a leading global tourist destination. 1. India has been elected to head the UN World Tourism Organisation (UNWTO), the highest policy making world tourism body represented by 150 countries. 2. The world's leading travel and tourism journal, "Conde Nast Traveller", ranked India as the numero uno travel destination in the world. 3. The Association of British Travel Agents (ABTA) has ranked India as No.1 amongst the top 50 places for 2006. 4. The "Incredible India" campaign has been ranked as the Highest Recall Advertisement worldwide by "Travel and Leisure". 5. India was adjudged Asia's leading destination at the regional World Travel Awards (WTA). 6. India's Taj Mahal continues to figure in the Seven Wonders of the World. 7. Bangalore-based Leela Palace Kempinski has been rated as the favourite business hotel in the world in a Readers' Choice Awards by Conde Nast Traveller. 3.5. Key Facts and Figures Indias travel and tourism is expected to generate Rs. 1,846.3 billion (US$ 38.8 bn) of economic activity (Total Demand) in 2004 growing (nominal terms) to Rs. 7.027.7 billion (US$ 90.4 bn) by 2014. Travel and tourism demand is expected to grow by 8.8 per cent per annum in real terms between 2004 and 2014. Employment The Indian travel and tourism economy employment is estimated at 24,456,600 jobs in 2004, 5.6 per cent of total employment, or one in every 17.8 jobs. By 2014, this should total 27.790.000 jobs. 5.7 per cent of total employment or one in every 17.5 jobs. The 11,404.000 travel and tourism industry jobs account for 2.6 per cent of total employment in 2004 and are forecast at 12.441200 jobs or 2.6 per cent of the total by 2014. Gross Domestic Product Indias travel and tourism industry is expected to contribute 2.0 per cent to Gross Domestic Product (GDP) in 2004 (Rs. 618.4 billion or US$ 13.00 billion), rising in nominal terms to Rs. 2,002.3 billion or US$ 25.8 billion (2.1 per cent of total) by 2014. The travel and tourism economy contribution (percent of total) should rise from 4.9 per cent (Rs 1,477.4 billion or US$ 31.1 billion) to 5.2 per cent (Rs 4,972.5 billion or US$ 64.0 billion) in this same period. Capital Investment India Travel & Tourism capital investment is estimated at Rs. 485.3 billion, US$ 10.2 billion or 7.2 per cent of total investment in year 2004. By 2014, this should reach Rs 1,663.9 billion US$ 21.4 billion or 7.8 per cent of total. Personal and Business Travel Tourism India Personal travel and tourism is estimated at Rs 927.3 billion. US$ 19.5 billion or 5.0 per cent of total personal consumption in year 2004. By 2014, this should reach Rs 3.612.9 bn. US$ 46.5 billion or 6.1 per cent of total consumption. India Business Travel is estimated at Rs 114.5 billion, US$ 2.4 billion in year 2004. By 2014, this should reach Rs 387.4 billion or US$ 5.0 billion.
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Export Visitor Exports play an important development role for the resident travel and tourism economy India travel and tourism is expected to generate 6.7 per cent of total exports (Rs 283.2 billion or US$ 6.0 billion) in 2004, growing (nominal terms) to Rs 1,267.3 billion or US$ 16.3 billion (5.4 per cent of total) in 2014. 4.0. Civil Aviation and Tourism In recent years, civil aviation in India has registered unprecedented growth. The domestic traffic rose from 13.3 million (133 lakh) in 2000 to 22.3 million (223 lakh) in 2005 registering annual growth of 18%. The low cost carriers are able to successfully woo the upper class railway and road passengers in 2006, the domestic passenger traffic rose by 43%. The domestic air freights particularly the express and perishable segments have added new markets. The international passenger and cargo traffic during the same period registered growth of 9.8% and 10.5% respectively. India has opened up its sky. In recent years it has signed liberal Air Services Agreements with many countries resulting in substantial increase of seats offered to and from India. The number of seats offered increased from 22 million (220 lakh) in 2003 to 46.5 million (465 lakh) in 2006. Experts are of the view that respectable growth in air traffic will be seen in the next 10-15 years. This sudden spurt in traffic has led to congestion at airports, suggesting urgent up gradation/augmentation of airport infrastructure. High powered group headed by Prime Minister of India estimates an investment of the order of US$ 102.5 million (INR 40, 000 crores) in the airport sector in the next 5-7 years. To meet these challenges, the Ministry of Civil Aviation and Airports Authority of India have decided to liberally involve private sector in the development and management of airports. The approved automatic investment route allows FDI up to 49% in the airport sector.
Domestic air traffic could more than quadruple by 2015...

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 0 5 10 15 20 25 30 35 40 22.37 25.75 27.5 29.4 31.37 33.5 35.8 38.21 40.81 43.6 45 50
Source: Business Today September 2007.. Numbers are passenger movement in million Two green field airports namely New International Bangalore airport and New International Hyderabad airport are being developed with the help of private sector (a consortium of Indian and foreign airports/companies). They are expected to be opened in 2008. Last year, the running airports at New Delhi and Mumbai were given to Joint Venture Companies for management and urgent development of infrastructure. The route followed in awarding these projects has stood the scrutiny by The Supreme Court of India. Therefore awarding any new project following the said route should pose no difficulty to the Government.
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New Mumbai airport is also on the horizon. Its project cost is estimated around (US$ 1153.8 million) INR 45000 million. In this case route taken in awarding New Bangalore and Hyderabad International airports will be followed. New airports at Goa, Pune, Greater NOIDA and Kunnar are also in the pipeline. In addition Airports Authority of India has announced 35 non-metro airports for up gradation under the public privatization partnership model. These are other good opportunities.
.. and international traffic double

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 0 5 10 15 20 25 30 35 40 22.37 25.75 27.5 29.4 31.37 33.5 35.8 38.21 40.81 43.6 45 50
Source: Business Today September 2007.. Numbers are passengers movement in millions Current Development In June 2006, the Committee of Infrastructure approved development of 35 non-metro airports. These include Ahmedabad, Amritsar, Agatti, Aurangabad, Agartala, Agra, Baroda, Bhopal, Bhubaneshwar, Chandigarh, Coimbatore, Dehradun, Dimapur, Guwahati, Jaipur, Jammu, Khajuraho, Nagpur, Patna, Portblair, Pune, Rajkot, Ranchi, Raipur, Goa, Imphal, Indore, Lucknow, Madurai, Mangalore, Trichy, Trivandrum, Udaipur, Visakhapatnam and Varanasi. The 35 non-metro airports approved for development are well-spreadfrom the extreme South (Thiruvananthapuram) to North (Jammu) and extreme East (Imphal) to West (Rajkot) of the country. The land area of these 35 airports including that of Civil Enclaves vested with the Airports Authority of India (AAI) range from 15 acres to1500 acres. Based on the decision of the Committee on Infrastructure, following actions are proposed with regard to development of these 35 non-metro airports of AAI: Airports Authority of India to undertake air side development of all the 35 non-metro airports including the Terminal Buildings. The commercial management of Terminal Buildings, constructed by AAI, will be so organized as to optimize revenue generation as also user convenience. City-side development of all the non-metro airports will be done through Public Private Partnership (PPP) and endeavour should be made to maximize non-aeronautical revenue.
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WHOS BUYING WHAT? Everyones expanding fleet. Air Deccan 56 A320s, 25 ATR 72s Air India 15 777-300ERs 6 77-200 LRs 27 787-8 Dreamliners Air India Express 9 737-800s Go Air 10 A320s Indian Airlines 40 A321/320/319s Indigo 89 A320s Jet Airways 10 Boeing 777-300ERs, 10 Being 787 Dreamliners. 8 Airbus A330-200s, 2 737-800s Jet Lite 10 Boeing 737-800s Kingfisher 30 Airbus A319/320/321s, 5 Airbus A330-200s 5 Airbus-500s, 5 Airbus A350XWBs, 5 Airbus A380s Paramount 10 Embraer E170s (Expected to order 25 more E170/175 aircraft) Spice Jet 5 737-900ERs, 17 737-800s
Source: Business Today September 2007..
As sated earlier, the development work on the airside will be undertaken by AAI. Broadly, the development on airside involve construction of new terminal building(s) or expansion of existing terminal building(s); extension of runway / taxiway; construction of additional parking stands / remote parking bays; taxiway and associated infrastructure.
INTERNATIONAL PLANS Air India Started non-stop service between Mumbai and New York (JFK) New Delhi- New York and Bangalore San Francisco on the cards Plans to increase connectivity from other Indian cities once fleet of 787 Dreamliners comes on board from mid-2008 Increase destinations served in Asia and restart services to Australia Join an International airline alliance, maybe Star Alliance headed by Lufthansa Jet Airways Make Brussels a European Scissor Hub where flights from India will arrive and then proceed to North American destinations after swapping passengers. Started long-haul services from Mumbai, Delhi and Bangalore to North America. Start services via Shanghai to San Francisco in 2008 depending on Chinese permission Increase capacity on Southeast Asia routes by deploying Airbus A330 instead of Boeing 737 aircraft. Kingfisher/Air Deccan If granted approvals will start Bangalore San Francisco flights in April May 2008, when it receives the Airbus A340-500 aircraft. Order more Airbus A380 aircraft to offer additional uplift from India. Get Air Deccan to start low-far services to West and Southeast Asia from various points in India.
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There will be investment opportunity for private sector to participate in the city side development of selected non-metro airports where sufficient land is available and potential exists to provide utility and facility needed for air passengers / travelling public and airport users and employees at airports. Development of 35 non-metro airports terminal buildings envisages the following: Modular Design Air-conditioning system Aero-bridges with glass walls Walkways CUTE (Common User Terminal Equipment) Escalators In-line baggage screening for check-in Improved signage
Jet Airways Indian Air Deccan Air India Kingfisher Jetlife Air India Express Alliance Air Indigo Spocejet Paramount Go Air 0 4 10 20 30 40 50 60 5 11 10 14 16 24 30 32 41 60
62
70
Source: Business Today September 2007.. How They Stack Up Jet is by far the biggest private operator as on July 31/07 THE INDIA FILE
Fleet size on March 31,04 No. of scheduled aircraft departures per day; 740 Domestic International No. of scheduled passengers carried per day: 55,259 (03-04) Domestic International Foreign Airlines carried 28, 246 passengers and 1,447 t of cargo during 03-04 Average Pax. Load Factor: 65.5% Domestic International
158 642 98 42,951 12,308
58.4% 72.5%
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Scheduled Cargo carried per day (T) Domestic International Total no. of Employees (as on Mar 31st) No. of Pilots No. of Technical employees Cabin Crew No. of Employees per aircraft: 287
Source: The Economic Ti mes, Chennai 27th April 2005.
541.1 267.7 1,605 10, 535 4,238
PARKING SLOTS
No. Airports No. of Passenger Embarked 10907 8337 3685 3550 3421 2145 998 970 742 653 1. MUMBAI 2. DELHI 3. BANGALORE 4. CHENNAI 5. KOLKATA 6. HYDERABAD 7. AHMEDABAD 8. GOA 9. GUWAHATI 10. COCHIN Source: DGCA No. of Outbound Aircraft Movements Per Day 137 80 49 35 44 31 15 12 12 11
AIRPORT STATUS REPORT Theres some progress at the major airports. New Delhi New Code F compliant CAT3B Runway 10R/28L to be operational by mid-2008 New domestic terminal under construction to be operational by mid-to-late 2008 All-new integrated Terminal 3 under construction with 74 aerobridges; to be operational by 2010 Mumbai New domestic terminal ready for use Slum rehabilitation work underway; delayed due to unavailability of land records Drainage systems improved, o major closures at the airport this monsoon Chennai Land acquired for expansion of parking bays and construction of parallel runway; to be operational by end-2008 or early-2009 Hyderabad New airport to be operational by March-April 2008 Bangalore New airport to be operational by April-May 2008 Kolkata Work stalled due to workers union, unavailability of land
Source: Business Today September 2007.
Indias 10 Busiest Airports

Mumbai Delhi Chennai Bangalore Kolkata Hyderabad Cochin Ahmedabad Goa Trivandrum Total Traffic at Indias airports Domestic 1,49 crore 1.38 crore 60.8 lakh 68.64 lakh 51.88 lakh 45.35 lakh 11.35 lakh 20.86 lakh 18.1 lakh 5.95 lakh 7.06 crore International 73.47 lakh 66.53 lakh 28. 96 lakh 12.61 lakh 8.05 lakh 12.15 lakh 14.29 lakh 4.05 lakh 4.03 lakh 11.86 lakh 2.57 crore Total 2.22 crore 2.04 crore 89.74 lakh 81.25 lakh 59.93 lakh 57.5 lakh 25.63 lakh 24.91 lakh 22.12 lakh 17.81 lakh 9.63 crore % change from 2005 -06 20.9 25.9 32.4 43.7 36 43.9 35.9 31.6 32.2 34.4 31.4
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Total top ten Indian airports accounted for 83.6 per cent of all passenger numbers Mumbai and Delhi alone accounted for 44.3 per cent of total air passenger traffic..
Air Deccan IndiGo Spice Jet Go Air Fleet size 437.82 19.63 457.45 -183.78 Cities served 474.89 161.93 636.82 33.14 Expected fleet size 358.7 177.38 536.08 -22.59 Profit/Loss* 397.99 32.16 430.15 -94.88
Cost Involved The estimated cost of development and modernization of 35 non-metro airports is Rs. 5500 crores 4.2. Tourism and Hospitality Hospitality The booming tourism industry has had a cascading effect on the hospitality sector with an increase in the occupancy ratios and average room rates. While occupancy ratio is around 75-80 per cent, the average increase in room rates has been hovering around 22-25 per cent. And with the continuing surge in tourist inflow, this sector is likely to offer tremendous opportunity for investors. For example, while the estimated number of required hotel rooms is around 240,000, the current availability is just 90,000 rooms - leaving a shortfall of 150,000 rooms to be provided. With such a huge potential available in this segment, several global hotel chains like the Hilton, Accor, Marriott International, Berggruen Hotels, Cabana Hotels, Premier Travel Inn (PTI), InterContinental Hotels group and Hampshire among others have all announced major investment plans for the country. The Government's move to declare hotel and tourism industry as a high priority sector with a provision for 100 per cent foreign direct investment (FDI) has also provided a further impetus in attracting investments in to this industry. It is estimated that the hospitality sector is likely to see US$ 11.41 billion in the next two years, with around 40 international hotel brands making their presence in the country by 2011. Simultaneously, international hotel asset management companies are also likely to enter India. Already, US-based HVS International has firmed up plans to enter India, and industry players believe others like Ashford Hospitality Trust and IFA Hotels & Resorts among others are likely to follow suit. New Room Supply 2006-2011
Markets Delhi/NCR Mumbai Kolkata Chennai Bangalore Hyderabad Pune Goa Cochin Jaipur Total Growth Percent Impact Multiple 2005 7,030 7,402 1,354 2,075 1,906 1,442 510 2,252 354 1,298 25,623 2006 182 0 75 0 270 286 100 60 82 41 1,096 2% 2007 2,207 996 710 778 470 565 275 469 6,440 12% 6 2008 2,720 860 210 460 2,216 1,633 1,221 550 453 720 11,043 21% 10 2009 3,132 2,827 1,380 1,942 2,570 3,584 2,347 1,015 330 975 20,102 38% 18 2010 2,280 3,840 525 650 1,415 455 220 517 200 400 10,502 20% 10 2011 335 825 275 645 335 980 165 215 165 3,940 7% 4
Source: T3 Travel Trends Today January 2007.
4.3. Government initiatives To unlock the huge potential in this sector, the Government has taken various initiatives for the development of this sector. Launch of Incredible India campaign to promote tourism both in domestic and international markets. Recognition of spare rooms available with various house owners by classifying these facilities as "Incredible India Bed and Break fast Establishments"', under 'Gold' or 'Silver' category. A new category of visa, "Medical Visa" ('M'-Visa), has been introduced which can be given for specific purpose to foreign tourists coming into India.
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Guidelines have been formulated by Department of AYUSH prescribing minimum requirements for Ayurveda and Panchkarma Centres. Ministry of tourism has tied up with United Nations Development Programme (UNDP) to promote rural tourism. 4.4. Tourism in Tamil Nadu Key Facts and Figures Tourist Arrivals in Tamil Nadu 2006 (Centre-Wise)
S.No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29 Destination Chennai Elagiri Mamallapuram Kancheepuram Tiruttani Chidambaram Pitchavaram Udhagamandalam Coonoor Mudumalai Thanjavoor Velankanni Nagore Poompuhar Madurai Kodaikanal Palani Rameswaram Courtallam Panchalankurichi Kanniyakumari Tiruchirappalli Salem Yercaud Hogenakkal Tiruchendur Coimbatore Kumbakonam Tiruvannamalai Grand Total Domestic 73,12,540 51,058 11,42,690 12,44,945 8,26,806 3,26,890 4,704 30,76,519 2,70,261 39,769 10,66,776 5,50,432 4,30,912 13,266 40,00,476 29,80,711 2,78,415 24,34,661 6,39,683 6,549 15,52,726 19,54,136 6,64,666 3,86,823 2,16,175 17,91,850 15,15,374 6,78,827 37,89,081 3,92,14,721 Foreign 5,64,780 8,600 1,18,885 63,273 13,326 11,589 820 1,08,020 4,038 5,580 42,705 7,185 1,598 1,050 99,970 78,885 7,106 7,849 3,145 61 53,861 81,639 1,992 2,124 1,141 9,356 21,341 6,920 8,822 13,35,661 Total 78,77,320 59,658 12,61,575 12,75,218 8,40,132 3,38,479 5,524 31,84,539 2,74,299 45,349 11,09,481 5,57,617 4,32,510 14,316 41,00,446 30,59,596 2,85,521 24,42,510 6,42,828 6,610 16,06,587 20,35,775 6,66,658 3,88,947 2,17,316 18,01,206 15,36,715 6,85,747 37,97,903 4,05,50,382
Source : Tamil Nadu Tourism News letter.
Domestic tourist arrival to Tamil Nadu

400 Tourist Arrival (In Lakhs) 350 300 250 200 150 100 50 0 2000 2001 2002 2003 Years 2004 2005 2006 230 238 246.61 300.77 270.59 323.39 392.14
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Foreign Tourist Arrival to Tamil Nadu

14.00 Tourist Arrival (In Lakhs) 12.00 10.00 8.00 6.00 4.00 2.00 0.00 2000 2001 2002 2003 Years 2004 2005 2006 7.86 7.73 8.05 9.02 10.58 13.35 11.79
Foreign Exchange Earned in Tamil Nadu

3,500 Tourist Arrival (In Lakhs) 3,000 2,500 2,000 1,500 1,000 500 0 2000 2001 2002 2003 Years 2004 2005 2006 1,788 1,750 1,809 2,283 1,913 2,556 3,020
Source: Tamil Nadu Tourism News letter.
4.5. Medical Tourism in India - Opportunities After Information Technology (IT) and Information Technology enabled Services (IteS), which are currently good contributors to our nations GDP, the next big thing happening (already begun!!!) could be medical tourism, which has enormous potential, if rightly tapped, to make great contributions to the nations GDP. The following will illustrate a few valid points by way of experts questions vs. opinions offered, current statistics available with future projections and a few suggestions for making best use of medical tourism towards the development of the countrys economic prosperity. Sharing of a wonderful experience by a foreign national: For thousands of medical tourists like George Marshall, this debate is invisible. In 2004, a heart bypass was recommended for the 73-year-old British citizen, which would have cost him up to 20,000. I had to wait for over three months to see the cardiologist and potentially a further six months for the operation, he said. Instead, he paid 4,400 to Wockhardt Hospitals for the operation. Airfare and travel insurance cost extra, and he paid with his own money, as insurance couldnt cover his outsourcing of medical needs. Existing offers available for medical tourists: Currently, the offers available today for similar patients are specialised services ranging from cardiology and cardiac surgery (angioplasty, bypass, valve replacement), to oncology and onco-surgery, organ transplants (liver and kidney), bone marrow transplants, joint replacements, eye surgery and in-vitro fertilisation. The cost differential is significant, as it was for Marshall, for the patients. Reason for going in for medical tourism: Medical tourism is attracting people from all over the industrialised world, from countries with relatively poor healthcare infrastructures and, in case of the US, places with exorbitantly expensive health care systems. Medical tourists from the US are usually those seeking procedures not covered by their insurers, those seeking necessary procedures and who are provided with incentives to find lower cost options, and those
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who cannot secure medical insurance where they depend on the procedures and the physicians. Cosmetic procedures are easily found in South America, while complex heart and orthopedic procedures are found in India, Thailand and Singapore, and specialised in-vitro fertilisation can be found in South Africa, Israel and Spain. In the global medical tourism industry, from cosmetic surgery to complex oncology, bargain prices can be found at a medical centre somewhere in the world. Time and money provide the incentives for seeking healthcare outside country. In the case of public health systems with long delays, such as Britain, time is the motivation. Accredited hospitals are potential winners in wooing medical tourist. Quality is a concern for potential medical tourists and what are now being called offshore hospitals address their concern by seeking and obtaining accreditation from bodies such as Joint Commission International (JCI), a subsidiary of the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), which offers accreditation to hospitals in the US. Several other hospitals that are offering medical tourism in India meet or exceed the standards of care of the finest hospitals located in US. Some advantage in availing this service: The lower cost structure of these hospitals allows them to be more generous with resources for their wellpaying clients. Nurse-to-patient ratios are higher, private rooms are readily available and family members are often included in the trip and made comfortable in luxury facilities that resemble five-star hotels. Dr Milica Bookman, professor of economics at St. Josephs University in Philadelphia, US, is author of the book Medical Tourism in Developing Countries. According to her research on the economic impact of medical tourism, 750,000 Americans are expected to have travelled abroad for treatment in 2007 and over six million will be doing by 2010. Some findings done through a study report by a global agency: According to a study by global accounting and consulting firm Ernst and Young and the Federation of Indian Chambers of Commerce and Industry (FICCI), private hospitals in India earned Rs 62,000 corer in fiscal 2006 and revenues from the sector are expected to rise up to Rs 130,000 crores (at current prices and exchange rates) in 2012, which represents an annual revenue growth rate of about 19 per cent a year. Our Finance Ministrys projections on GDP: The Finance Ministrys Investment Commission emphasises that healthcare delivery is already one of the largest service-sector industries in India, and expects the industry to grow and contribute up to five per cent of GDP (at around Rs. 240,000 crores) by 2010. Comments offered by lead hospital spokesperson: The sector is getting focused from an investment perspective, said Vishal Bali, chief executive of Wockhardt Hospitals, who plans to double its hospitals to 30 from 15 in time span of two years. The drivers for the future are falling in place. At the same time, Dr Pratap C Reddy, chairman of the Apollo Hospitals Group, explained: We need to invest $60-70 billion over the next five years in hospitals and healthcare education to expand this sector and reach out to masses as soon as possible. Comments offered by other professionals in this field: Ravi Duggal, a researcher with the Mumbai-based policy analysis group, Centre for Enquiry into Health and Allied Themes, explained, The problem starts when a developing country, which has 75 per cent of its population either poor living at subsistence level, collaborates in promoting medical tourism when it cannot meet the basic healthcare needs of a majority of its citizens. Medical tourism creates a climate of inequitable services that undermine the goal of health for all, in the view of Dr Nergis Mistry, scientific researcher with the Foundation for Medical Research, Mumbai. Mistry warns against a technology and urban-centred approach to delivering health care: It raises the cost of healthcare for the local population because it forces the use of expensive technology and drugs. Number of people having visited India for as medical tourists: India now hosts and treats an estimated of 50,000 medical tourists a year and the catalytic CII-McKinsey report of 2002 projected that medical tourism could contribute up to Rs 10,000 crores in revenue by the year 2012.
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Existing guidelines seem to be inadequate: In the major states, health departments issue guidelines to private hospitals specifying their obligation to provide beds, treatment and services to the public patient, and to return a portion of revenues from medical tourism into serving the public health overburden, but neither are these hospital held to account on these points by their respective state governments, nor does a standard country-wide regulatory system exist to ensure such compliance. Benefits are accruing only to private sectors: A signal of state-directed change however comes from Tamil Nadu, Karnataka and Andhra Pradesh. As of now, it is only the private sector that is reaping the benefits of medical tourism in Tamil Nadu, while the government sector remains out of this loop so far: We have been focusing on public health. However, with the concept of pay wards coming up in government hospitals for certain field segments; we can expect this trend to change. State wise preparation in progress: Karnataka is now preparing to promote premier government institutions as medical tourism destinations. The department of Tourism with the Health and Family Welfare department has identified centres of excellence in the government health sector such as Jayadeva Institute of Cardiology and the Kidwai Institute of Oncology which will be promoted abroad as places for specialised treatment at affordable costs. Moreover, what is now being called the Andhra Pradesh model stems from the provision of universal health insurance in three districts, and AP chief minister YS Rajasekhara Reddy has called for bids in six other districts. Apollo Hospitals emphasised, insurance cover and accessibility can drive change. In Aragonda, Andhra Pradesh, with a contribution of a rupee a day a constables son was able to have a bone marrow transplantation done at the best facility. Nobody can afford to pay for major illnesses, and we need a mechanism to make hospital procedures cashless. That is possible only with insurance. After going through the above, what could be the wish list of a common man for making medical tourism a big success for India? Some of these are summarized below: Let there be an identical agency like NAASCOM for medical tourism to periodically come out realistic reports for bettering the services in the days to come. Why only private sector gains - why not public sector too, from the earnings of medical tourism - a thorough study need to be done by involving the experts. The rates charged or services offered could be further subsidised so that people from different parts of the world throng to our hospitals for getting timely, immediate and quality care all at an affordable cost so that at least by word of mouth the message gets well spread across different sections of the societies. ESI hospitals too can join this race by selectively opening up their doors so that their income gets a big boost, which could be optimally utilised for bettering the services from all angles benefiting the registered care seeker. Let our foreign consulate offices act as ambassadors for promoting medical tourism to get this business a big boost. Let there be innovative schemes by targeting medical tourists so that they return back with great feeling of comfort, satisfaction and joy. Let there be more and more infrastructure avenues opened up so that consultants can join the fray for bringing in world class quality treatment facilities, all under one roof. Let our doctors who are serving out of India and willing to come back be encouraged to the fullest for doing their best to give a big push to this trade. More and more top class colleges are set up in the country, with foreign collaboration, so that aspiring students lovingly join this profession to earn their degree (doctorate) for serving the society and mankind. Before, concluding, lets hope our countrys overall infrastructure moves fast on issues like good quality roads, international airports, best of the five star /three star hotels at affordable rates, best pick up and return conveyance, sight seeing points made more visible and attractive and customer care from start to finish is of the highest order.
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Lastly, lets hope our GDP do get a boost of at least 5 per cent and more in the near future so that the economy keeps growing at a fast rate. Medical Tourism in Tamil Nadu Envisioning the potential of medical tourism in the state. Tamil Nadu has come a long way in carving a niche for itself in this field. Toda, medical tourism in India is synonymous with Tamil Nadu, and Chennai, Vellore, Madurai and Coimbatore have a stellar role to play in the burgeoning medical tourism industry. Tamil Nadu is a pioneer in providing the best healthcare. Ultra-modern corporate hospitals, talented medical professionals, and battalions of paramedics and the best practices of Government hospitals the states, have attracted people to the state to receive excellent treatment, convalesce in enchanting locals, and recuperate swiftly. Hospitals in Tamil Nadu cater to the treatment of various disease, like MIOT for orthopaedics (joint and bones) and traumatology, Shankar Netralaya for ophthalmology (eye procedures); Christian medical college for open-heart surgery; Madras Medical Mission for heart surgery; Kovai Medical Centre and Hospital for arthroscopicm Laparoscopic and thoracoscopic surgeries. Apollo for hip and total-knee replacement, liver, multi-organ and cord blood transplants, to name a few. The government medical college- Stanely Medical College is well known for its gastrointestinal procedures. Also the Government-led General Hospital is well known for providing services for up to 7,000 in patients alone. The investment in public sector hospitals is substantial, which they are able to offer state-of-the- art operation theatres and technology at cost-effective prices. Healthcare in Tamil Nadu has earned a good reputation in the country because both the private as well as the government hospitals are so professionally run. With almost all government-run and private hospitals introducing newer technologies and better services in the healthcare sector, it has fallen upon the medical sector to benchmark medical standards in the country. In fact, the Tamil Nadu Medical Services Corporation has an excellent tract record for its streamlined processes for the distribution of drugs. The all- computerised system of the corporation allows the procurement to be 25-30 per cent less than the market rate. The quality, too, is ensured, as private laboratories test every batch of medicines independently. The system is totally supportive and foolproof, which is how it is able to leverage competitive rates. As a result, all government hospitals are free from the hassle of procurement of drugs and equipment. In a bid to promote medical tourism, the government has identified 25 city hospitals to help showcase medical tourism as well as inaugurated an exclusive Medical Tourism Desk at the Tamil Nadu Tourism Complex. The medical tourism desk would be manned by trained hospital staff to help tap the vast potential of medical tourism. Further, Indonesia is showing interest in medical tourism initiatives of Tamil Nadu Government and has requested Tamil Nadu Tourism to organise a Medical Tourism Fair with participation from super speciality hospitals of the state at Jakarta. The request was put forward during the four-day Pacific Asia Travel Association (PATA) Travel Mart held at Bali, where Tamil Nadu Tourism had a stall at the Incredible India pavilion. The Government of India is so taken with this high level of competence that it would like the other states to emulate the Tamil Nadu model. Some of Tamilnadus most reputed Multi specialty Hospitals and Health Care Centre
Hospitals 1. Lifeline Multi Specialty Hospital, Chennai 2. Spot Hospital, Chennai 3. Cholayil Sanjeevanam, Chennai 4. Rajan Eye Care Hospital, Chennai 5. Prasanth Multispeciality Hospital, Chennai Website www.lifeline-hospital.com www.spothospital.com www.cholayilsanjeevanam.com http://lasikpavilion.com www.pfrcivf.com
Some of Tamilnadus most reputed Health care facilities:

1. Apollo Hospital, Chennai 2. Sri Ramachandra Medical Centre (SRMC), Chennai 3. Madras Medical Mission, Chennai 4. M.V. Diabetes Speciality Centre (MVDSC), Chennai 5. MIOT Hospitals, Chennai
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6. Sankara Nethralaya, Chennai 7. Frontier Lifeline, Chennai 8. Dr. Aggarwals Eye Hospital, Chennai 9. Vijaya Hospital, Chennai 10. Dr. Mehtas Hospital, Chennai 11. Solace Meditour Private Limited 12. Ayush Therapy Centre 13. K.G. Hospital, Coimbatore 14. Kovai Medical Centre and Hospital, Coimbatore 15. Ganga Hospital, Coimbatore 16. PSG Hospitals, Coimbatore 17. CMC, Vellore 18. Gandhiji Nature Cure Centre, Elagiri & Chennai Source: Tamil Nadu Tourism News letter.
5.1. The Wining mix for Health Tourism Ingredients for success Beyond the professionalism and technical expertise of medical staff or Travel agencies and Tour operators, the range of high quality healthcare and medical care products and services available at highly affordable prices and value for money, there are several other pluses that add to the attractiveness of the destination as a health tourism centre. 5.2. Tamil Nadus winning marketing mix includes A welcoming destination with an appreciation of the needs of different cultures and the availability of support services to serve diverse needs. Service Quality- Par Excellence with International Standard. Tamil Nadu- ness and Enchanting Tamil Nadu traditions Patients and users of other hospitals and allied services are welcomed as guests. Gracious and courteous reception is characteristic of traditional Tamil Nadu hospitality Destination diversity Tamil Nadu offers a myriad of enjoyable ways in which one can achieve a speedy recovery. Take life at a more leisurely pace at any of the hundred of Temples around Tamil Nadu enjoying the fresh mountain air or sun, sea and sand. Or simply indulge on a diet of delicious Tamil Nadu cuisines and health-restoring rejuvenating herbal therapies offered by Tamil Nadu resorts combined with mesmerising massage. Recuperating has never been more pleasurable. Attractive prices. Value for money, Guests and visitors are of the view that Tamil Nadu Medical Tourism offers value for money. There is no doubt that visitors seeking treatment in Tamil Nadu get more for only a fraction of what it costs back home leaving them with extra to spend on their favourite leisurely pursuits such as sight-seeing, shopping, Pilgrimage, Hill resorts ,Sandy beaches and beauty treatments, and other treats. 5.3. State Involvement and Implications It has to be done in Five major ways. First, tax incentives should be given to support the growth of healthcare corporations. Second, creating institutional infrastructure for upholding standards and quality the accreditation system, standardization guidelines, fee packaging guidelines, etc. And third, the Tamil Nadu Tourism should directly lead in the marketing of medical tourism overseas through trade missions and other promotional event activities. Fourth,Travel agencies and Tour Operators Co-ordination as selling the Brand of TamilNadu as Prime Medical Tourism Destination and Fifth, as forming Core Committee of Medical experts with field specialist to study the lacunae in enhancing the commodity of healthcare Internationally. 5.4. Additional FSI for hospitals will bring down healthcare cost in Medical Tourism in Tamil Nadu: "The Government of Tamil Nadu should hike the Floor Space Index (FSI) for hospitals and healthcare institutions from the current 1.5 to 5 to bring down the rising healthcare cost, increase number of beds and healthcare talent pool of the State," "The relaxation in FSI will allow hospitals and institutions create more infrastructure in the same premises. They do not have to invest as much as 40-50% of the project cost in acquiring new lands. Instead they can invest directly in healthcare equipments or human resources and reduce healthcare cost,"
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In a press release issued by CII , the increasing land prices in the State means that the land cost constitutes about 40-50% of a hospital project and with low FSI, hospitals are not able to increase beds in the same premises. They are not able to keep the healthcare cost at affordable level, when they acquire land to increase the number of beds. At present, there is only one bed for 1,100 people in Tamil Nadu, whereas the World Health Organisation recommends at least 1:500 ratio. The additional FSI of 5, as in Mumbai, would increase the number of hospital beds by approximately 20-30 %. FSI in Delhi and Karnataka is 3, as compared to just 1.5 in Tamil Nadu. FSI should be same across the State to benefit especially the small 20-bed hospitals - "the frontline brigades in the battlefield for saving lives of people in need of emergency treatment". These small hospitals constitute 80% of the total healthcare services provided in the State. At national level, India needs to double its bed strength of 7 lakhs to meet the WHO recommendation of 1 bed for 500 people. As the country adds 25 million children every year, India needs to invest Rs. 80,000 crore to create one lakh additional beds every year for the next 20 years, he said. In comparison, Japan has one bed for 90 people, while Russia and Western nations have one bed for 110 and 250 people respectively. "We cannot import healthcare like cement or steel. Hence, we have to improve our healthcare infrastructure on war footing." The Government should provide healthcare sector incentives that are equal to those provided to the IT sector, as healthcare has the potential to create employment opportunities five to ten times more than what the IT industry can do. The healthcare sector has the potential to increase its direct employment from 4 million to 30 million and generate an equal number of indirect employment opportunities. Healthcare is also a major foreign exchange earner with the inevitable growth of medical tourism. "In addition to that, over 10% of Indian medical professionals - including paramedical staff, who are working abroad, send, home about 60% of their earnings," There is acute manpower shortage in the people-intensive healthcare industry. Tamil Nadu produces 2000 doctors a year and for every doctor, there is a need for 5 Para medical staff - the State alone needs to produce 10,000 nurses per year. India has about 7 lakh doctors and 1.1 million nurses but the country needs at least 17 lakh doctors and 37 lakh paramedical staffs to meet the local demand. Manufacturing sector continues to downsize but hospitals world over continue to generate more employment. At US$ 3 trillion, it is one of the largest sectors of world economy. Other States to follow the healthcare model of Andhra Pradesh, which intends to cover 5 crore people - over 80% of its population - with its new universal healthcare scheme, Arogya Sree. AP too has a very liberal FSI to increase its healthcare infrastructure. 5.5. Challenges to the Industry Tamil Nadu is emerging as an attractive, affordable destination for healthcare But there are some challenges that the country has t overcome to become a tourist destination with competent health Care industry: A. Infrastructural facilities Roads Sanitation Power Backups Rest/ Guest Houses Public Utility Services B. The Foreign Customer Concerns and Expectations: The biggest challenge that the Indian hospitals face is assuring the foreign patients that they will receive quality care with no hidden costs. The industry experts need to develop the decision making models through a thorough study on the factors that motivate the patients to choose India as a health care solution spot. The basic expectations that the industry feels are important to be concerned about are: Hygiene Staff ( trained technically as well as in soft skills) Customization Insurance Cover Stability Connectivity International standard certification Para Medical Ambulance facilities ( to and fro from Airport).
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C. The Image of India needs to be enhanced (Standardization) The only one quality that Indian health industry lacks in is Health standards and hygiene. Indian hospitals lack accreditation from the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), suffer from a lack of standards in terms of quality and rates for healthcare procedures, have no gradation system and a far from perfect insurance sector. In addition, top Indian hospitals have high infection and mortality rates, and are unwilling to disclose data regarding these. Even if we were having the best of quality standards as has Indraprastha Apollo Hospital we will still be perceived as inferior in standards .This can be avoided by getting Quality standards .Apollo group of hospitals which has become the first hospital in India to get a JCI certification, the gold standard for US and European Hospitals. The same has to come to more hospitals of India. D. Market accessibility The next challenge for the Indian industry is to make the Indian market accessible by tourist travel agents and websites of Indian health tourism. The government can play a vital part as the same can bring in lots of foreign revenue. The major ways of promoting our health tourism could be: Tour operators and Travel agencies of India Doctors of India visiting foreign countries International standard certification C. The Image of India needs to be enhanced (Standardization) The only one quality that Indian health industry lacks in is Health standards and hygiene. Indian hospitals lack accreditation from the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), suffer from a lack of standards in terms of quality and rates for healthcare procedures, have no gradation system and a far from perfect insurance sector. In addition, top Indian hospitals have high infection and mortality rates, and are unwilling to disclose data regarding these. Even if we were having the best of quality standards as has Indraprastha Apollo Hospital we will still be perceived as inferior in standards .This can be avoided by getting Quality standards .Apollo group of hospitals which has become the first hospital in India to get a JCI certification, the gold standard for US and European Hospitals. The same has to come to more hospitals of India. D. Market accessibility The next challenge for the Indian industry is to make the Indian market accessible by tourist travel agents and websites of Indian health tourism. The government can play a vital part as the same can bring in lots of foreign revenue. The major ways of promoting our health tourism could be: State Tourism Offices in India and abroad. Doctors of India visiting foreign countries- Pre/Post treatment. International websites on Indian tourism with True Perceptions. Globalisation of marketing activities by Indian Tour & Travel Agents Tying up with foreign Travel Agents for promotion Insurance companies abroad who target customers E. Excess Glamourisation of Health Care It has been seen that the doctors and key player hospitals in India emphasis more on glamorization of health care than its actual advantages or research uniqueness. We need to work more on our research in medical field to be competent enough to beat our international competitor. In other words SERVICES should be given more attention and importance than PACKAGING. F. State Intervention As this is a product which needs international tie-ups and international marketing, the state should help in the same. It should help the companies, hospitals and states in promoting health tourism abroad so that we can tap a wider range of customers. G. Infrastructure Indian hospitals must create exclusive infrastructure for corporate medical tourism
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Chartered flight services, attractive tourism packages could be part of infrastructure There's growing pressure on U.S. corporate to reduce expenditure on healthcare H. Competition (Neighbouring countries) Countries that actively promote medical tourism include Cuba, Costa Rica, Hungary, India, Israel, Jordan, Lithuania, Malaysia and Thailand. Belgium, Poland and Singapore are now entering the field. South Africa specializes in medical safaris-visit the country for a safari, with a stopover for plastic surgery, a nose job and a chance to see lions and elephants. Thus India has enough competition from the international market .This will be one of our major threats in bringing up and developing the health tourism industry. I. Insurance Backup One good way of tapping the foreign customers is tying up with Insurance companies abroad who could provide a genuine database of target customers. They can benefit from us by our services. Thus this would become a way of mutual marketing tacit cs between the Indian health tourism industry and the foreign Insurance agencies. J. Local Demand vs. Global Demand It can be seen in case of hospitals like Apollo and Escorts that the Local demand itself to be catered to is vast. We should remember that we should have the facilities enough to manage the foreign customers not neglecting the local markets. Thus it is a challenge for both the Alternate therapy industry and Corporate Health Care Service Providers to cater to this vast market efficiently without compromises in quality on either side. Conclusion Tamil Nadu has long been a centre of ancient healing traditions based on herbal medicine and holistic treatments that have evolved from folk knowledge as well as Asian well-being therapies such as Indian Ayurvedic and Allopathic practices. With the growing popularity of holistic healing techniques that restore balance and rejuvenate mind, body and spirit, in addition to conventional medical treatment, Tamil Nadu offers a one-stop shop that leaves you looking good and feeling great from Hospital to Hospitality. References
Business Today, March 11 (2007). Public Health, Private Opportunity. Business Today, September 9 (2007). Wind Under their Wings. Modern Medicare, March (2007). Where does India Stand? Tamil Nadu Tourism News Letter. Published by Tamil Nadu Tourism, Chennai The Economic Times, Chennai, 27th April (2005). Pronto! Indian Aviation Goes Jet-Setting. Travel Trend Today, January (2007), On the Emerging Trends in the Indian Hotel Industry, Vol.23, Issue No.1.
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*Lecturer in Tourism Management, Tagore Government Arts College, Pondicherry. murugan_33@hotmail.com

Source : Emst & Young Report: Cumulative investments

Source : Ernst & Young Report

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Source : Emst & Young Report: Cumulative investments

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Source: Modern Medicare March 2007.

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

State/UT Andhra Pradesh Karnataka Kerala Tamil Nadu Pondicherry

Death Rate Urban 5.4 5.6 6.1 5.6 5.4

Total 8 7.2 6.3 7.6 6.3

Infant Mortality Rates - 2003 Infant Mortality Rate Rural Urban 67 33 61 24 12 10 48 31 33 17

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Domestic air traffic could more than quadruple by 2015...

.. and international traffic double

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

158 642 98 42,951 12,308

541.1 267.7 1,605 10, 535 4,238

Indias 10 Busiest Airports

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Source: Business Today September 2007..

Source: T3 Travel Trends Today January 2007.

Source : Tamil Nadu Tourism News letter.

Domestic tourist arrival to Tamil Nadu

Source : Tamil Nadu Tourism News letter.

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

Foreign Tourist Arrival to Tamil Nadu

Source : Tamil Nadu Tourism News letter.

Foreign Exchange Earned in Tamil Nadu

Source: Tamil Nadu Tourism News letter.

Some of Tamilnadus most reputed Health care facilities:

Conference on Tourism in India Challenges Ahead, 15-17 May 2008, IIMK

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