3rd Sem Mba Project

A Project Report On

“Medical Tourism in India”
For the partial fulfillment of the requirement for the award of Master of Business Administration in Health Care Services (2011-2012)

Submitted By: Suneel Kulkarni MBAHCS 4th Sem 621033968

Lotus Clinical Research Academy Pvt. Ltd. # 582, KCA Enclave Opp. Bethany School, 8th Block, Koramangala Bangalore - 560 095. Karnataka. INDIA Learning Centre Code: 59076

Medical Tourism in India
By Suneel Kulkarni A project report submitted in partial fulfillment of the requirements for the degree of Master of Business Administration in Healthcare Services of Sikkim Manipal University, INDIA.

Sikkim-Manipal University of Health, Medical and technological sciences Distance Education wing Syndicate House Manipal – 576 104

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STUDENT DECLARATION

I hereby declare that the project report entitled “Medical Tourism in India” Submitted in the partial fulfillment of the requirements for the degree of Master of Business Administration in Healthcare Services to Sikkim-Manipal University, India, is my original work and not submitted for the award of any other degree, diploma, fellowship, or any other similar title or prizes.

Place: Bangalore Date:

Suneel Kulkarni (Name of Candidate) 621033968 (Registration No.)

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EXAMINER’S CERTIFICATE

The project report of MR. Suneel Kulkarni On “MEDICAL TOURISM IN INDIA” Is approved and is acceptable in quantity and form

Internal Examiner
(Name, qualification & designation)

External Examiner
(Name, qualification)

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UNIVERSITY STUDY CENTRE CERTIFICATE

This is to certify that the project report entitled “MEDICAL TOURISM IN INDIA” Submitted in the partial fulfillment of the requirements for the degree of Master in Business Administration in Healthcare Services of Sikkim-Manipal University of Health, and Technology Sciences MR. Suneel Kulkarni Has worked under my supervision and guidance and no part of this report has been submitted for the award of any other degree, diploma, fellowship, or any other similar titles or prizes and the work has not been published in any Journal or Magazine. Certified

(Guide’s Name and qualification)
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Table of contents

S.NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

CONTENTS HEALTH CARE IN INDIA- VISION 2020 RESEARCH AND METHODOLOGY EXECUTIVE SUMMARY AN INTRODUCTION MEDICAL TOURISM IN INDIA SWOT ANALYSIS WHAT IS INDIA OFFERING SCOPE AND OPPORTUNITY INDIA’S FUTURE PROSPECTS COST COMPARISION MAJOR PLAYERS MEDICAL PACKAGES CONCLUSION RECOMMENDATIONS BIBLIOGRAPH Y

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Key linkages in health Health and health care need to be distinguished from each other for no better reason than that the former is often incorrectly seen as a direct function of the latter. Heath is clearly not the mere absence of disease. Good Health confers on a person or groups freedom from illness - and the ability to realize one's potential. Health is therefore best understood as the indispensable basis for defining a person's sense of well being. The health of populations is a distinct key issue in public policy discourse in every mature society often determining the deployment of huge society. They include its cultural understanding of ill health and well-being, extent of socio-economic disparities, reach of health services and quality and costs of care and current bio-medical understanding about health and illness. Health care covers not merely medical care but also all aspects pro preventive care too. Nor can it be limited to care rendered by or financed out of public expenditure- within the government sector alone but must include incentives and disincentives for self care and care paid for by private citizens to get over ill health. Where, as in India, private out-of-pocket expenditure dominates the cost financing health care, the effects are bound t be regressive. Heath care at its essential core is widely recognized to be a public good. Its demand and supply cannot therefore, be left to be regulated solely by the invisible had of the market. Nor can it be established on considerations of utility maximizing conduct alone. What makes for a just health care system even as an ideal? Four criteria could be suggested- First universal access, and access to an adequate level, and access without excessive burden. Second fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity and a constant search for improvement to a more just system. Third training providers for competence empathy and accountability, pursuit of quality care ad cost effective use of the results of relevant research. Last special attention to vulnerable groups such a children, women, disabled and the aged. Forecasting in Health Sector In general predictions about future health - of individuals and populations - can be notoriously uncertain. However all projections of health care in India must in the end rest on the overall changes in its political economy - on progress made in poverty mitigation (health care to the poor) in reduction of inequalities (health inequalities affecting access/quality), in generation of employment /income streams (to facilitate capacity to pay and to accept individual responsibility for one's health ). In public information and development communication (to promote preventive self care and risk reduction by
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conducive life styles ) and in personal life style changes (often directly resulting from social changes and global influences). Of course it will also depend on progress in reducing mortality and the likely disease load, efficient and fair delivery and financing systems in private and public sectors and attention to vulnerable sections- family planning and nutritional services and women's empowerment and the confirmed interest of me siat-e 10 ensure just health care to the Largest extent possible. To list them is to recall that Indian planning had at its best attempted to capture this synergistic approach within a democratic structure. It is another matter that it is now remembered only for its mixed success. Available health forecasts There is a forecast on the new health challenges likely to emerge in India over the next few decades. Murry and Lopez <WorId Bank B 2000> have provided a possible scenario of the burden of disease (BOD) for India in the year 2020, based on a statistical model calculating the change in DALYS are applied to the population projections for 2020 and conversely. The key conclusions must be understood keeping in the mind the tact that the concept of DALYs incorporates not only mortality but disability viewed in terms of healthy years of life lost. In this forecast, DALYs are expected to dramatically decrease in respect of diarrheal diseases and respiratory infections and less dramatically for maternal conditions. TB is expected to plateau by 2000, and HIV infections are expected to rise significantly up to 2010. Injuries may increase less significantly, the proportion of people above 65 will increase and as a result the burden of noncommunicable disease will rise. Finally cardiovascular diseases resulting any from the risk associated with smoking urban stress and improper diet are expected to increase dramatically. Under the same BOD methodology another view is available from a four - state analysis done in 1996 <World Bank B 2000> these four states - AP, Karnataka, W. Bengal and Punjab - represent different stages in the Indian health transition. The analysis reveals that the poorer and more populated states. West Bengal will still face a large incidence of communicable diseases. More prosperous states, such as Punjab further along the health transiting will witness sharply increasing incidence of non-communicable diseases especially, in urban areas. The projections highlight that we still operating on unreliable or incomplete base data on mortality and causes of death in the absence of vital registration statistics and know as yet little about how they differ between social classes and regions or about the dynamic patterns of change at work. It also highlights the policy dilemma of how to balance between the articulate middle upper class demand for more access to technologically advanced and subsidized clinical services and the more pressing needs of the poor for coverage of basic disease control interventions. This conflict over deployment of public resources will only get exacerbated in future. What matters most in such estimates are not
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societal averages with respect to health but sound data illumining specifically the health conditions of the disadvantaged in local areas <Gwatkin A 2000> that long tradition of health sector analysis looking at unequal access, income poverty and unjustly distributed resources as the trigger to meet health needs of the poor. That tradition has been totally replaced by the currently dominant school of international thought about health which is concerned primarily with efficiency of systems measured by cost effectiveness criteria. Future of State Provided Health Care Historically the Indian commitment to health development has been guided by two principles-with three consequences. The first principle was State responsibility for health care and the second (after independence) was free medical care for all (and not merely to those unable to pay). The first set of consequences was inadequate priority to public health, poor investment in safe water and samtati on and to the neglect of the key role of personal hygiene in good health, culminating in the persistence of diseases like Cholera. The second set of consequences pertains to substantially unrealized goals of NHP 1983 due to funding difficulties from compression of public expenditures and from organizational inadequacies. The ambitious and far reaching NPP 2000 goals and strategies have however been formulated on that edifice in the hope that the gaps and the inadequate would be removed by purposeful action. Without being too defensive or critical about its past failures, the rural health structure should be strengthened and funded and managed efficiently in all States by 2005. This can trigger many dramatically changes over the next twenty years in neglected aspects or rural health and of vulnerable segments. The third set of consequences appears to be the inability to develop and integrate plural systems of medicine and the failure to assign practical roles to the private sector and to assign public duties for private professionals. To set right these gaps demanded patient redefinition of the state's role keeping the focus on equity. But during the last decade there has been an abrupt switch to market based governance styles and much influential advocacy to reduce the state role in health in order to enforce overall compression of public expenditure an reduce fiscal deficits. People have therefore been forced to switch between weak and efficient public services and expensive private provision or at the limit forego care entirely except in life threatening situations, in such cases sliding into indebtedness. Health status of any population is not only the record of mortality and its morbidity profile but also a record of its resilience based on mutual solidarity and indigenous traditions of self-care - assets normally invisible to the planner and the professional. Such resilience can be enriched with the State retaining a strategic directional role for the good health of all its
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citizens in accordance with the constitutional mandate. Within such a framework alone can the private sector be engaged as an additional instrument or a partner for achieving shared public health outcomes. Similarly, in indigenous health systems must be promoted to the extent possible to become another credible delivery mechanism in which people have faith and away fond for the vat number of less than folly qualified doctore in rural areas to get skills upgraded. Public programs in rural and poor urban areas engaging indigenous practitioners and community volunteers can prevent much seasonal and communicable disease using low cost traditional knowledge and based on the balance between food, exercise medicine and moderate living. Such an overall vision of the public role of the heterogeneous private sector must inform the course of future of state led health care in the country. Key Achievements in Health Our overall achievement in regard to longevity and other key health indicators are impressive but in many respects uneven across States, The two Data Annexure at the end indicate selected health demographic and economic indicators and highlight the changes between 1951and 2001. In the past five decades life expectancy has increased from 50 years to over 64 in 2000. IMR has come down from 1476 to 7. Crude birth rates have dropped to 26.1 and death rates to 8.7. At this stage, a process understanding of longevity and child health may be useful for understanding progress in future. Longevity, always a key national goal, is not merely the reduction of deaths as a result of better medical and rehabilitative care at old age. In fact without reasonable quality of life in the extended years marked by self-confidence and absence of undue dependency longevity may men only a display of technical skills. So quality of life requires as much external bio-medical interventions as culture based acceptance of inevitable decline in faculties without officious start at sixty but run across life lived at all ages in reduction of mortality among infants through immunization and nutrition interventions and reduction of mortality among young and middle aged adults, including adolescents getting inform about sexuality reproduction and safe motherhood. At the same time, some segments will remain always more vulnerable - such as women due to patriarchy and traditions of infrafamily denial), aged (whose survival but not always development will increase with immunization) and the disabled (constituting a tenth of the population). Reduction in child mortality involves as much attention to protecting children from infection as in ensuring nutrition and calls for a holistic view of mother and child health services. The cluster of services consisting of antenatal services, delivery care and post mortem attention and low birth weight, childhood diarrhea and ARI management are linked priorities. Programme of immunization and childhood nutrition seen in better performing stats indicate
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sustained attention to routine and complex investments into growing children as a group to make them grow into persons capable of living long and well Often interest fades in pursuing the unglamorous routine of supervised immunization and is substituted by pulse campaigns etc. Which in the long run turn out counter-productive. Indeed persistence with improved routines and care for quality in immunization would also be a path way to reduce the world's highest rate of maternal mortality. In this context we may refer to the large ratio-based rural health infrastructure consisting of over 5 lakh trained doctors working under plural systems of medicine and a vast frontline force of over 7 lakh ANMs, MPWS and Anganwadi workers besides community volunteers. The creation of such public work force should be seen as a major achievement in a country short of resources and struggling with great disparities in health status. As part of rural Primary health care network lone, a total of 1.6 lakh subcenters, (with 1.27 lakh.' ANMa in position) and 22975 PHCs and 2935 CHCs (with over 24000 doctors and over 3500 specialists to serve in them) have been set up. To promote Indian systems of medicine and homeopathy there are over 22000 dispensaries 2800 hospitals Besides 6 lakh angawadis serve nutrition needs of nearly 20 million children and 4 million mothers. The total effort has cost the bulk of the health development outlay, which stood at over Rs 62.500/- crores or 3-64 % of total plan spending during the last fifty years. On any count these are extraordinary infrastructural capacities created with resources committed against odds to strengthen grass roots. There have been facility gaps, supply gaps and staffing gaps, which can be filled up only by allocating about 20% more funds and determined ill to ensure good administration and synergy from greater congruence of services, but given the sheer size of the endeavor thee wilt always be some failure of commitment and in routine functioning. These get exacerbated by periodic campaign mode and vertical programme, which have only increased compartmentalized vision and over-medicalization of health problems. The initial key mistake arose from the needless bifurcation of health and family welfare and nutrition functions at all levels instead of promoting more holism. As a result of all this the structure has been precluded from reaching its optimal potential. It has got more firmly established at the periphery/sub-center level and dedicated to RCH services only. At PHC and CHC levels this has further been compounded by a weak referral system. There has not been enough convergence in "escorting" children through immunization coverage and nutrition education of mothers and ensuring better food to children, including cooked midday meals and health checks al schools. There has also been no constructive engagement between allopathic and indigenous systems to build synergies, which could have improved people's perceptions of benefits from the infrastructure in ways that made sense to them.

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One key task in the coming decades is therefore to utilize fully that created potential by attending to well known organizational motivational and financial gaps. The gaps have arisen partly from the source and scale of funds and partly due to lack of persistence, both of which can be set right. PHCs and CHCs are funded by States several of whom are unable to match Central assistance offered and hence these centers remain inadequate and operate on minimum efficiency. On the other hand over two thirds cost of three fourths of sub-centers are fully met by the Center due to their key role m family welfare services. But in equal part these gaps are due to many other non-monetary factors such as undue centralization and uniformity, fluctuating commitment to key routines at ground level, insufficient experimentation with alternatives such as getting public duties discharged through private professionals and ensuring greater local accountability to users. Health Status issues The difference between rural and urban indicators of health status and the wide interstate disparity in health status are well known. Clearly the urban rural differentials are substantial and range from childhood and go on increasing the gap as one grows up to 5 years. Sheer survival apart there is also the known under provision in rural areas in practically all social sector services. For the children growing up in rural areas the disparities naturally tend to get even worse when compounded by the widely practiced discrimination against women, starting with foeticide of daughters. In spite of overall achievement it is a mixed record of social development specially failing in involving people in imaginative ways. Even the averaged out good performance ides wide variations by social class or gender or region or State. The classes in many States have had to suffer the most due to lack of access or denial of access or social exclusion or all of them. This is clear from the fact that compared to the riches quintile, the poorest had 2.5 times more IMR and child mortality, TFR at double the rates and nearly 75% malnutrition particularly during the nineties. Not only are the gaps between the better performing and other States wide but in some cases have been increasing during the nineties. Large differences also exist between districts within the same better performing State urban areas appear to have better health outcomes than rural areas although the figures may not fully reflect the situation in urban and peri-urban slums with large in migration with conditions comparable to rural pockets. It is estimated that urban slum population will grow at double the rate of urban population growth in the next few decades. India may have by 202 a total urban population of close to 600 million living in urban areas with an estimated 145 million living in slums in 2001. What should be a fair measure for assessing success in enhancing health status of population I any forecast on health care?
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Disease Load in India and China: We need a basis for comparative scenario building. Among the nations of the world China alone rank in size and scale and in complexity comparable to India differences between an open and free society and a semi-controlled polity do matter. The remarkable success in China in combating disease is due to sustained attention on the health of the young in China, and of public policy backed by resources and social mobilization- While comparing China and India in selected aspects of disease load, demography and public expenditures on health, the record on India may seem mixed compared to the more all round progress made by china. But this should also be seen in the perspective of the larger burden of disease in India compared to china and of the transactional costs of an open and free democracy. Though India and China recorded the same rate of growth till 70s, China initiated reforms a full decade earlier. This gave it a head start for a higher growth rate and has resulted in an economic gap with India which has become wider over time. This is because domestic savings in China are 36% of GDP whereas in India it hovers at 23%, mostly in house-hold savings. Again China attracted $40 billion in foreign direct investment against $2 billion in India. Special economic zones and relaxed labour laws have helped. Public expenditure on health in China has been consistently higher underlining the regressive nature of financing of health is in India. Nevertheless- it is not too unrealistic to expect that India should be able to reach by 2010 at least three fourth the current level of performance of China in all key health indices. India's current population is not a bit more than 75% that of China and India will of course be catching up even more with China into the 21 century. This would be offset by the handicap that Indian progress will be moderated by the fact that it is an open free and democratic society. A practical rule-of-thumb measure for an optimistic forecast of future progress in India could be - that between 2000 and 2010 India should do three fourths as well as China did in 1990-2000 and, after 2010, India should try to catch up with the rate of performance of China and do just as well thereafter. This will translate into, for, instance, a growth rate of about 8% for India till 2010 and as close to 10% as possible thereafter thus enabling doubling first in ten years and doubling first in ten year and doubling twice over every seven years thereafter prior to 2025. keeping this perspective in mind, we may now examine the profile of major disease control effort; the effectiveness of available instruments for delivery and financing public health action and assess factors relevant to the remaining event of vulnerability within JOUT emerging social pyramid over next two or three decades.

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Major Disease Control Efforts A careful analysis of the Global Burden of Disease (GBD) study focusing on age-specific morbidity during 2000 in ten most common diseases (excluding injuries) shows that sixty percent of morbidity is due to infectious diseases and common tropical diseases, a quarter due to life-style disorders and 13% due to potentially preventable pre-natal conditions. Further domestic R&D has been so far muted in its efforts against estimated annual aggregate health expenditure in India of Rs- 80,000/-crores R&D expenditure in India for public and private sector combined was Rs 1150 crores only. India must play a larger part in its own efforts at indigenous R&D as very little world-wide expenditure on R&D is likely to be devoted to infectious diseases. For instance out of the 1233 new drugs that came into the market between 1975 and 1997 only 11 were indicated specifically for tropical country diseases, We have already the distinction of elimination or control acceptable to public health standards of small pox and guinea worm diseases. In the draft National Health Policy -21 It has now been proposed to eliminate or control the following diseases within limits acceptable to public health practice- A good deal of the effort would be feasible. • Polio Yaws and leprosy by 2005 which seems distinctly feasible though the removal of social stigma and reconstructive surgery and other rehabilitation arrangements in regard to leprosy would remain inadequate for a decade or more. • Kalaazar by 20I0 and Filalriasis by 2010 which also seems feasible due to its localized prevalence and the possibility of greater community based work involving PR institutions in the simple but time-limited tasks or public health programs• Blindness prevalence to 0.5% by 2010 sees less feasible due to a graying population. At present the programme is massively supported by foreign aid as there are many other legitimate demands on domestic health budgets• AIDS reaching zero growth by 2007 appears to be problematic as there are disputes even about base data on infected population. On most reckonings, affordable vaccines re not likely to be available soon nor anti-retro viral drugs appear likely at affordable prices in the near future. Further the prevalence curve of Aids in India is yet to show its shape. There is also larger unresolved question of where HIV/ATDS should be fitted in our priorities of public health, especially in this massively foreign aided programme what happen if aid does not become available at some point.

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Unfinished burden of communicable diseases: Apart from the above, there remains a vast unfinished burden in preventing controlling or eliminating other major communicable diseases and in bringing down the risk of deaths in maternal and peri-natal conditions. Endemic diseases arising from infection or lack of nutrition continue to account for almost two thirds of morality ad morbidity India. Indeed eleven out of thirteen diseases recommended by the Bhore Committee were infectious diseases and at least three of them may well continue to be with us for the next two decades Baring Leprosy which is almost on the path to total control by 2005, the other key communicable diseases will be TB Malaria and Aids- to which diarrhea in children and complicated and high risk maternity should be added in view of their pervasive incidence and avoidable mortality among the poorer and underserved sectors. Tuberculosis: Tuberculosis has had a worldwide resurgence including in India. It is estimated that about 14 million persons are infected, i.e. 1.55 of total population suffer from radio logically active Tuberculosis. About 1.5 million cases are identified and more than 300 000 deaths occur every year Between NFHS 1 and NFHS 2 the prevalence has increased from 4678 per lakh population to 544. Unfortunately, prevalence among working age adults (15-59) is even higher as 675. All these may well be underestimates in so far as patients are traced only through hospital visit. Only about half reach the hospital. Often wrong diagnosis by insufficiently trained doctors or misunderstood protocols is another key problem both public and private sectors. TB is a wide spread disease of poverty among women living and working in ill ventilated places and other undernourished persons in urban slums it is increasingly affecting the younger adults also in the economically productive segments. No universal screening is possible. Sputum positive test does not precede diagnosis but drugs are prescribed on the basis of fever and shadows as a result incomplete cure becomes common and delayed tests only prove the wrong diagnosis too late. Improved diagnosis through better training and clear protocols and elimination of drug resistance through incomplete cure should be priority. Treatment costs in case of drug resistance can soar close to ten times the normal level of Rs. 3000 to 4000/-per person treated. Similarly even though the resistant strain may cover only 8% at present, it could suddenly rise and as it approaches 200/o or so, there is a danger that TB may get out of control. The DOTS programme trying for full compliance after proper diagnosis is settling down but already has some claims of success. More than 3000 laboratories have been set up for diagnosis and about 1.5 lakh workers trained and with total population coverage by 2007 cure rates (already claimed to have doubled) may rise substantially. There is
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reason to hope that DOTS programs would prove a greater success over time with increased community awareness aeneration. The key issue is how soon and how well can it be integrated into the PHC system and made subject to routines of local accountability, without which no low cost regime of total compliance is feasible in a country as large as India. An optimistic assessment could be that with commitment and full use of infrastructure it will be possible to arrest further growth in absolute numbers of TB cases keeping it at below 1.5 million till 2010 even though the populations will e growing. Once that is done TB can be brought down to less than a million lie within internationally accepted limits and disappears as a major communicable disease in India by 2020. Malaria: As regards malaria, we have had a long record of success and failure and each intervention has been thwarted by new problems and plagued by recrudescence. At present India has a large manpower fully aware of all aspects of malaria about often low in motivation. It can be transformed into a large-scale work force for awareness generation, tests and distribution of medicine. In spite of past successes, there is evidence of reemergence with focal attacks of malaria with the virulent falciparum variety especially m tribal areas. Priority tnbal area malaria stands fully funded by the center. About 2 millioncases of malaria are recorded allover India every year with seasonal high incidence local failures of control. Drug resistance in humans and insecticide resistant strains of mosquitoes present a significant problem. But there is a window of opportunity I respect of DDT sensitive areas in eastern India where even now malaria incidence can be brought down by about 50% within a decade and be beneficial for control of kalazar and JE. There is growing interest and community awareness of biological methods of control of mosquito growth. Unfortunately diligent ground level public health work is in grave disarray n these areas but can be improved by better supervision greater use of panchayatraj institutions and buildings on modest demonstrated successes. As regards a vaccine, there seems t be no sufficient incentive for international R&D to focus on a relatively lower priority or research. Roll back malaria programmes of the WHO are more likely to concentrate on Africa whose profile of malaria is not similar to ours. The search for a vaccine continues but has little likelihood of immediate success. In spite of various difficulties, if the restructuring of the malaria work force and the strengthening of health infrastructure takes place, one can expect that the incidence can be reduce by a third or even upto half in the next decade or so. For this it is necessary that routine tasks like timely spraying and logistics for taking blood slides testing and their analysis and organic methods of reducing mosquito spread etc. Are down staged to community level and penormed under supervision throLigh panchayais wiih comaiLiniLy participation public
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education and local monitoring. Malaria can certainly be reduced by a third even upto a half in ten years, and there is a prospect of near freedom from malaria for most of the country by 2020. The case of AIDS: There is finally the case of HIV AID. The magnitude in the numbers of HIV infected and of AIDS patients by 2025 can be known only as trends emerge over a decade from now. When better epidemiological estimates are available but at present these figures are hotly contested. 'We can’t start with the number infected with HIV as per NACO sentinel surveillance in 2000 a cumulative total 3.86 million, a figure disputed in recent public health debate. We can then assume that about 10% will turn into full-blow cases of severe and intractable stage of Aids. There is as yet no basis to know how many of those infected will become AIDS patients, preventive efforts focused on behavior change will show up firmly only after a decade or so. During this period one can assume an additional 10% growth to account for new cases every year. The Draft NHP 2001 seeks to stop further infection by educating and counseling and condom supplies to level it off around 2007, which seems somewhat ambitious. We have yet to make a decisive dent into the problem of awareness with the broader population and so far we have been at work only on high risk groups. NFHS2 shows only a third of woman reporting that they even knew about the HIV/AIDS. Further such awareness efforts must be followed by multi-pronged and culturally compatible techniques of public education that go beyond segments easier to be convinced or behavior changed. There are voices already raised about the appropriate lateness of IEC mass media content and of the under emphasis of face to face counseling, calling for innovative mobilization strategies rooted in indigenous belief systems. What it implies is that we may be carrying by 2015closeto 5 million infected and upto a tenth of them could turn into full blown cases. We may not be able to level off infection by 2007 Further these magnitudes may turn out m actual fact to be wildly off the mark. On any account it is clear that AIDS can lead to high mortality among the productive groups in society affecting economic functioning as also public health. Even if 10% of them say 50 to 60000 cases becomes full blown cases the state has the onerous and grim choice to look at competing equities and decide on a policy for free treatment of AIDS patients with expensive anti-retro viral drugs. And if it decides not to, the issue remains as to how to evolve humane balanced and affordable policies that do not lead to a social breakdown. In about a decade vaccine development may possibly be successful and drugs may by more effective but they may not always be affordable nor can be given free. There would hopefully be wider consultation with persons with caring sensibilities including AIDS patients on how to counsel in different
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eventualities and to get the balance right between hospital and home care and how to develop a humane affordable policy for anti retroviral drugs for AIDS patients. Is there a case for providing them with drug free of cost merely to extend their lives for few years? The matter involves a true dilemma, for public health priorities themselves certainly argue for more funds should address diseases constituting bigger population based hazards. Investments made m such expensive interventions can instead be made in supporting hospice efforts in the voluntary and private sectors. Whatever position may emerge in research or spread of infection of case fatalities, a multi pronged attempt for awareness, must continue and tough choices must get discussed openly without articulate special, often urban middle class interests denying other views and especially public health priorities of the poor. The promotion of barrier protection must increase but has to related to a system of values, which would be acceptable to the people’s beliefs. We need to strengthen sentinel surveillance systems and awareness effort. We also need sensitive feedback on the effects they leave on younger minds for a balanced culturally acceptable strategy. All this is feasible and can be accomplished if we are not swept away by the power of funding and advocacy and fear of being accused to be out of line with dominant world opinion. In any case many of the ill cannot afford the high prices or have access to it from public agencies. The strict patent regimen under TRIPS is bound to prevail, notwithstanding the ambivalently worded Doha decision of WTO that public health emergencies provide sufficient cause of countries to use the flexibility available from various provisions of TRIPS. A recent analysis reveals that the three drug regimen recommended will cost $10000 per person per year from Western companies and the treatment will be life-long. Three Indian companies are offering to Central Government anti retro; viral drugs at $600/ Rs. 30,000/per person per year and to an international charity at an even lower price $ 350/ Rs. 13,000/per year provided it was distributed for humanitarian relief free in S. Africa. It has been public policy in Brazil that the drug is supplied free to all AIDS should be no exception. If drugs are supplied acting on a public health emergency basis and prices can stabilize at Rs. 1000/or so per year the public health budget should be able to accommodate the cost weighed against true public criteria. But the aim of leveling off infection of 2007 still seems unlikely. Maternal and Parental Deaths: Maternal and parental deaths are sizeable but the advantage here is that they can be prevented merely by more intensive utilization of existing rural health infrastructure. Policy and implementation must keep steady focus on key items such as improved institutional deliveries better trained birth attendants and timely antenatal screening to eliminate anemia and at the same time isolate cases needing referral or other targeted attention. After all Tamil Nadu has by
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such methods ensured closed to 90% institutional deliveries backed by a functional referral. Firm administrative will and concurrent supervision of specified screening tasks included in MCH services can give us a window of opportunity to dramatically bring down within a few years alarming maternal mortality currently one of the highest in the world. From NFHS I data, it was estimated at 424 per lakh births it has risen to 540 per lac births in NFHS II, but the WHO estimate puts it higher at 570. There can be a systematic campaign over five years to increase institutional deliveries as near as possible to the Tamil Nadu level, also taking into account assisted, home deliveries by trained staff with doctors at call. For the interim TBAs should be relied on through a mass awareness campaign involving Gram Panchayats too. Over a period of time there is no reason why ANMs entitled benefits of children to help in their growth and not remain as welfare measure. Using the infrastructures fully and with community participation and extensive social mobilization many tasks in nutrition are feasible and can be in position to make impact by 2010. Child Health and Nutrition: Associated with this is the issue of infant and child mortality, (70 out of 1000 dying in the first year and 98 before vide years) and low birth weight (22% UW at birth and 47% EJW at below 3 years) most mortality occurs from diarrhoea and the stagnation in IMR in the last few year is bound to have a negative effect on population stabilization goals. A recent review of the Ninth plan indicated that even with accelerated efforts we may reach at best IMR/50 by 3002, but more like IMR/56. since the easier part of the problem is taking child mortality is over every pomt gain hereafter will deal with districts at greater risk and needing better organizational efficiencies in immunization. At the same time, more streamlined RCH services are getting established as part of public systems and through private partnerships Therefore there is every reason to hope that the NPP 2000 target of 30 per thousand live births by 2010 will be met barring a few pockets of inaccessible and resource lean areas with stubborn persistence of poverty and dominantly composed of weaker sections (e g in part of Orissa as seen from NFHS II). As regards childhood diarrhoea, deaths are totally preventable simple community action and public education by targeting children of low birth weights and detecting early those children at risk from malnutrition through proper low cost screening procedure, the present arrangement has got too burdened with attempting total population coverage getting all children weighed even once in three months and making ANMs depots for ORS and for simple drugs for fever and motivating the community to take pride in healthy children are the lessons of the success of the Tamil Nadu Nutrition Project, If this is done there is a reasonable chance of two thirds decline in moderate malnutrition and abolition of serious grades completely by 2015. The success can be built upon till 2025 for reaching levels comparable to China.
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Concentration on preventive measures of maternal and child health and in particular improved nutrition services will be particularly useful because it will help that generation to have a head start in good health who are going to be a part of the demographic bonus. The bonus is a young adult bulge of about 340 million (with not less than 250 million from rural population and about 100 million born in this century). The bonus will appear in a sequence with South Indian States completing the transition before North Indian States spread it over the next three decades- To ensure best results all this stage the present nutritional services must be converted into targeted (and entitled) benefits of children to help in their growth and not remain as welfare measure. Using the infrastructures fully and with community participation and extensive social mobilization many tasks in nutrition are feasible and can be in position to make impact by 2010. Mild and moderate malnutrition still prevalent in over half of our young population can be halved if food as the supplemental pathway to better nutrition becomes a priority both for self reliance and lower costs. There has been a tendency for micro nutrient supplementation to overwhelm food derived nourishment. This trend is assisted by foreign aid but over a long run may prove unsustainable- By engaging the adolescents into proper nutrition education and reproductive health awareness we can seamlessly weave into the nutritional security system of our country a corps of informed interconnected and imaginative ideas can be tried out. Such social mobilization at low cost can be the best preventive strategy as has been advocated for long by the Nutrition Foundation of India (< Gopalan 2001) and can be a priority in this decade over the next two plan periods. Unfinished agenda - non communicable diseases and injuries: Three major such diseases viz, cancer cardiovascular diseases and renal conditions - and neglect in regard to mental health conditions - have of late shown worrisome trends. Cures for cancer are still elusive in spite of palliatives and expensive and long drawn chemo - or radio -therapy which often inflict catastrophic costs, In the case of CVD and renal conditions known and tried procedures are available for relief. There is evidence of greater prevalence of cancer even among young adults due to the stress of modern living. In India cancer is a leading cause of death with about 1.5 to 2 million cases at anytime to which 7 lac new cases are added every year with 3 lakh deaths. Over 15 lakh patients require facilities for diagnosis and treatment. Studies by WHO show that by 2026 with the expected increase in fife expectancy, cancer burden in India will increase to about 14 lac cases. CVD cases and Diabetes cases are also increasing with an 8 to 11 % prevalence of the latter due to fast life styles and lack of exercise. Traumas and accidents leading to injuries- are offshoots of the same competitive living conditions and urban traffic conditions Data show one death every minute due to accidents or more than 1800 deaths every day- in
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Delhi alone about 150 cases are reported every day from accidents on the road and for every death 8 living patients are added to hospitals due to injuries. There is finally the emerging aftermath of insurgencies and militant violence leading to mental illnesses of various types. It is estimated that 10 to 20 persons out of 1000 population suffer from severe mental illness and 3 to 5 times more have emotional disorder. While there are some facilities for diagnosis and treatment exist in major cities there is no access whatever in rural areas. It is acknowledged that the only way of handling mental health problems is through including it into the primary health care arrangements implying trained screening and counseling at primary levels for early detection. All these are eminently feasible preventive steps and can be put into practice bv 2005 and we should be doing as well or better than China by 2020 considering the greater load of non communicable diseases they bear now. The burden of non-communicable diseases will be met more and more by private sector specialized hospitals which spring up in urban centers. Facilities in prestigious public centers will also be under strain and they should be redesigned to take advantage of community based approach of awareness, early detection and referral system as in the mode) developed successfully in the Regional Cancer Center Keraia. Public sector institutions are also needed to provide a comparator basis for costs and evaluating technology benefits.' For the less affluent sections prolonged high tech cure will be unaffordable. Therefore public funds should go to promote a routine of proper screening health education and self care and timely investigations to see that interventions are started in stages I and II. Health Infrastructure in the Public Sector Issues in regard to public and private health infrastructure are different and both of them need attention but in different ways. Rural public infrastructure must remain in mainstay for wider access to health care for all without imposing undue burden on them. Side by side the existing set of public hospitals at district and sub-district levels must be supported by good management and with adequate funding and user fees and out contracting services, all as part of a functioning referral net work. This demands better routines more accountable staff and attention to promote quality. Many reputed public hospitals have suffered from lack of autonomy inadequate budgets for non-wage O&M leading to faltering and poorly motivated care. All these are being tackled in several states are part health sector reform, and will reduce the waste involved in simpler cases needlessly reaching tertiary hospitals direct These, attempts must persist without any wavering or policy changes or periodic denigration of their past working. More autonomy to large hospitals and district public health authorities will enable them to plan and implement decentralized and flexible and locally controlled services and remove the dichotomy between hospital and primary care services. Further most preventive services can be delivered by down staging to a public health nurse much of what a doctor alone does now.
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Such long term commitment for demystification of medicme and down staging of professional help has been lost among the politicians bureaucracy and technocracy after the decline of the PHC movement. One consequence is the huge regional disparities between states which are getting stagnated in the transition at different stages and sometimes, polarized in the transition. Some feasible steps in revitalizing existing infrastructure are examined below drawn from successful experiences and therefore feasible elsewhere, Feasible Steps for better performance: The adoption of a ratio based approach to creating facilities and other pulls has led to shortfalls estimated up to twenty percent. It functions well where ever there is diligent attention to supervised administrative routines such as orderly drugs procurement adequate O&M budgets and supplies and credible procedures for redressal of complaints. Current PHC CHC budgets may have to be increased by 10% per year for five years to draw level. The proposal in the Draft NHP 2001 is timely that State health expenditures be raised to 7% by 2015 and to 8% of State budgets thereafter. Indeed the target could be stepped up progressively to 10% by 2025. it also suggests that Central funding should constitute 25% of total public expenditure in health against the present 15%. The peripheral level at the sub center has not been (and may not now ever be) integrated with the rest of the health system having become dedicated solely to reproduction goals. The immediate task would be to look deepening the range of work done at all levels of existing centers and in particular strengthen the referral links and fuller and flexible utilization of PHC/CHCs. Tamil Nadu is an instance where a review showed that out of 1400 PHCs 94% functioned in their own buildings and had electricity, 98% of ANMs and 95% of pharmacists were in position. On an average every PHC treated about 100 patients 224 out of the 250 open 24 hour PHCs had ambulances. What this illustrates is that every State must look for imaginative uses to which existing structures can be put to fuller use such as making 24 hours services open or trauma facilities in PHCs on highway locations etc. The persistent under funding of recurring costs had led to the collapse of primary care in many states, some spectacular failures occurring in malaria and kalazar control. This has to do with adequacy of devolution of resources and with lack of administrative will probity and competence in ensuring that determined priorities in public health tasks and routines are carried out timely and in full. Only genuine devolution or simpler tasks and resources to panchayats, where there will be a third women members- can be the answer as seen in Kerala or M.P. where panchayats are made into fully competent local governments with assigned resources and control over institutions in health care. Many innovative cost containment initiatives are also possible through focused management - as for instance in the streamlining of drug purchase
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stocking distribution arrangements in Tamil Nadu leading to 30% more value with same budgets. The PHC approach as implemented seems to have strayed away from its key thrust in preventive and public health action. No system exists for purposeful community focused public information or seasonal alerts or advisories or community health information to be circulated among doctors in both private practice and in public sector. PHCs were meant to be local epidemiological information centers which could develop simple community. Tertiary hospitals had been given concessional land, customs exemption and liberal tax breaks against a commitment to reserve beds for poor patients for free treatments. No procedures exist to monitor this and the disclosure systems are far from transparent, redressal of patient grievances is poor and allegations of cuts and commissions to promote needless procedure are common. The bulk of non-corporate private entities such as nursing homes are run by doctors and doctors- entrepreneurs and remain unregulated cither in terms of facility of competence standards or quality and accountability of practice and sometimes operate without systematic medical records and audits. Medical education has become more expensive and with rapid technological advances in medicine, specialization has more attractive rewards. Indeed the reward expectations of private practice formerly spread out over career long earnings are squeezed into a few years, which becomes possible only by working in hi tech hospital some times run as businesses. The responsibilities or private sector in clinical and preventive public health services were not specified though under the NHP 1983 nor during the last decade of reforms followed up either by government of profession by any strategy to engage allocate, monitor and regulate such private provision nor assess the costs and benefits or subsidization of private hospitals. There has been talk of public private partnerships, but this has yet to take concrete shape by imposing pubic duties on private professionals, wherever there is agreement on explicitly public health outcomes. In fact it has required the Supreme Court to lay down the professional obligations of private doctors in accidents and injuries who used to be refused treatment in case of potential becoming part of a criminal offence. The respective roles of the public and private sectors in health care has been a key issue in debate over a long time. With the overall swing to the Right after the 1980s, it is broadly accepted that private provision of care should take care of the needs of all but the poor. Hi doing so, risk pooling arrangements should be made to lighten the financial burden on theirs who pay for health care. As regards the poor with priced services. Taking into account the size of the burden, the clinical and public health services cannot be shouldered for all by government alone. To a large extent this health sector reform m India at the state level confirms this trend. The distribution of the burden, between the two sectors would depend on the shape and size of the social pyramid in each
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society. There is no objection to introduce user fees, contractual arrangements, risk pooling, etc. for mobilization of resources for health care. But, the line should be drawn not so much between public and private roles, but between institutions and health care run as businesses or run in a wider public interest as a social enterprise with an economic dimensions. In a market economy, health care is subject to three links, none of which should become out of balance with the other - the link between state and citizens' entitlement for health, the link between the consumer and provider of health services and the link between the physician and patient. Health Financing Issues Public expenditure levels Fair financing of the costs of health care is an issue in equity and it has two aspects how much is spent by Government on publicly funded health care and on what aspects? And secondly how huge does the burden of treatment fall on the poor seeking health care? Health spending in India at 6% of GDP is among the highest levels estimated for developing countries. In per capita terms it is higher than in China Indonesia and most African countries but lower than in Thailand. Even on PPP $ terms India has been a relatively high spender information sheets based on reporting from a network associating private doctors also as has been done successfully at CMC Vellore in their rural health projects or by the Khoj projects of the Voluntary Health Association of India. It is only through such community based approach that revitalization of indigenous medicines can be done and people trained in self care and accept responsibility for their own health. PHC approach was also intended to test the extent to which non-doctor based healthcare was feasible through effective down staging of the delivery of simpler aspects of a care as is done in several countries through nurse practitioners and physician assistants, ANMs; physician assistants etc can each get trained and recognized to work in allotted areas under referral/supervision of doctors. This may indeed be more acceptable to the medical profession than the draft NHP proposal to restart licentiates in medicine as in the thirties and give those shorter periods of training to serve rural areas. Such a licentiate system cannot now be recalled against the profession's opposition nor would people accept two level services. Finally it is important to note some dangers inherent arrangements to promote delivery systems substantially outside government channel either through NGOs or through registered societies at State and district levels. Clearly this may by a better approach than leaving it to the market and welcome as path breaking of innovative efforts as a precursor to launching a public program. But as a long run delivery mechanism it is neither practical nor sustainable as such arrangements tend to bypass government under our constitutional scheme of
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parliamentary responsibility and would also cut into the potential of panchayatsraj institutions. Each major disease control program has now got a separate society at state and district levels often as part of access to foreign aid. What is lost is the principle of parliamentary accountability over the flow of funds that arise out of voted budgets and international agreements to which Government is a party and answerable to parliament. Like campaign modes and vertical interventions, the registered society approach would weaken the long-term commitment and integrity of public health care systems. Shape of the Private Sector in the Medicine The key features of the private sector in medical practice and health care are well known. Two questions are relevant. What role should be assigned to it? How far and how closely should it be regulated? Over the last several decades, independent private medical practice has become widespread but has remained stubbornly urban with polyclinics, nursing homes and hospitals proliferating often through doctor entrepreneurs. At our level tertiary hospitals in major cities are in many cases run by business houses and use corporate business strategies and hi-tech specialization to create demand and attract those with effective demand or the critically vulnerable at increasing costs. Standards in some of them are truly world class and some who work there, are outstanding leaders in their areas. But given the commoditization of medical care as part of a business plan it has not been possible to regulate the quality, accountability and fairness in care through criteria for accreditation, transparency in fees, medical audit, accountable record keeping, credible grievance procedures etc. such accreditation, standard setting and licensure systems are best done under self regulation, but self regulation systems in India medical practice have been deficient in many respects creating problem in credibility. Acute care has become the key priority and continues to attract manpower and investment into related specialty education and facilities for technological improvement. Common treatments, inexpensive diagnostic procedures and family medicine are replaced and priced out of the reach of most citizens in urban areas. Public health spending accounts for 25% of aggregate expenditure the balance being out of pocket expenditure incurred by patients to private practitioners of various hues. Public spending on health in India has itself declined after liberalization from 1.3% of GDP in 1990 to 0.9% in 1999. Central budget allocations for health have stagnated at 1.3% to total Central budget. In the States it has declined from 7.0% to 5.5.% of State health budget. Consider the contrast with the Bhore Committee recommendation of 15% committed to health from the revenue expenditure budget, Indeed WHO had recommended 55 of GDP for health. The current annual per capita public health expenditure is no more than Rs. 160 and a recent World Bank review showed that over all primary health services account for 58% of public expenditure mostly but on salaries, and the secondary/tertiary sector for about 38%, perhaps the greater part going
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to tertiary sector, including government funded medical education. Out of the total primary care spending, as much as 85% was spent on or curative services and only 15% for preventive service. <World Bank 1995> about 47% of total Central and State budget is spent on curative care and health facilities. This may seem excessive at first sight but in face the figure is over 60% in comparable countries, with the bulk of the expenditure devoted publicly funded care or on mandated or voluntary risk pooling methods, in India close to 75% of all household expenditure on health is spend from private funds and the consequent regressive effects on the poor is not surprising. In this connection the proposals in the draft NHP 2000 are welcome seeking to restore the key balance towards primary care, and bring it to internationally accepted proportions in the course of this decade. Private expenditure trends: Many surveys confirm that when services are provided by private sector it is largely for ambulatory care and less for inpatient care. There are variations in levels of cost, pricing, transactional conveniences and quality of services. There is evidence to suggest that disparities in income as such do not make a difference in meeting health care costs, except for catastrophic or life threatening situations Finally it has been established that between 2/3rds to 3/4ths of all medical expenditure is spend on privately provided care every household on the average spends up to 10% of annual household consumption in meeting health care needs. This regressive burden shows up vividly in the cycle of incomplete cure followed by recurrence of illness and drug resistance that the poor face in diseases like TB or Kalazar or Malaria especially for daily wage earners who cannot afford to be out of work. Privatization has to be distinguished from private medical practice which has always been substantial within our mixed economy. What is critical however is the rapid commercialization of private medical practice in particular uneven quality of care. There are complex reasons for this trend. First is the high scarcity cost of good medical education, and second the reward differential between public and corporate tertiary hospitals leading to the reluctance of the young professional to be lured away from the market to public service in rural areas and finally there is the compulsion of returns on investment whenever expensive equipment in installed as part of practice. Increasingly, this has shifted the balance from individual practice to institutionalizes practice, in hospitals, polyclinics,- Etc. this conjunction explodes into unbearable cost escalation when backed by a third party payer system/- This in turn induces increases in insurance premiums making such cover beyond the capacity to pay. There is a distinct possibility of such cycles of cost escalation periodically occurring in the future, promoted further by global transfer of knowledge and software, tele-medicine etc. especially after the advent of predictive medicine and gene manipulation.
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Doctors practicing in the private sector are sometimes accused of prescribing excessive, expensive medicines and with using rampant and less than justified use of technology for diagnosis and treatment. Some method of accreditation of hospitals and facilities and better licensure systems of doctors is likely within a decade. This will enables some moderation in levels of charges in using new technology. High cost of care is sometimes sought to be justified as necessary due to defensive medicine practiced in order to meet risks under the Consumer Protection Act. There is little evidence from decisions of Consumer Courts to justify such fears. While the line between mistaken diagnosis and negligent behaviour will always remain thin, case law has already begun to settle around the doctor's ability to apply reasonable skills and not the highest degree of skill. What has lien established is the right of the patient to question the treatment and procedures if there is failure to treat according to standard medical practice or if less than adequate care was taken. As health insurance gets established it may impost more stringent criteria and restrictions on physician performance which may tempt them into defensive medicine. There may also be attempt to collusive capture and (indirect ownership) of insurance companies by corporate hospitals as in other countries. Advances in medical technology are rapid and dominant and easily travel worldwide and often seen as good investment and brand equity in the private sector. Private independent practices - and to smaller extent hospitals, dispensaries, nursing homes tele- are seen as markets for medical services with each segment seeking to maximize gains and build mutually supporting links with other segments. More than one study on the quality of care indicates that sometimes more services are performed to maximize revenue, and services/ medicines are prescribed which ffl-e not always necessary. Allegations are also widely made of collusive deals between doctors and hospitals with commissions and cuts exchanged to promote needless referral, drugs or procedures <World Bank A 1995> Appropriate regulation is likely in the next decade for minimum standards and accountability and that should consist of a balanced mix of self regulation external regulation by standard setting and accreditation agencies including private voluntary health insurance. How far can health insurance help? What constitutes a fair distribution of the costs of care among different social groups will always be a normative decision emerging out of political debate. It includes risk pooling initiatives for sharing costs among the healthy and the sick leading to insurance schemes as a substitute for or as supplementary to State provision for minimum uniform services. It also covers risk sharing initiatives across wealth and income involving public policy decisions on progressive taxation, merit subsidy and cross subsidization by dual pricing. Both will continue to be necessary in our conditions with more emphasis on risk sharing as growth picks up. Risk pooling within private voluntary and mandated insurance schemes has become inevitable in all countries because of the double
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burden of sickness and to ensure that financial costs of treatment do not become an excessive burden relative to incomes. It is difficult but necessary to embed these notions of fair financing into legislation, regulations and schemes and programs equity is aimed at in health care. With the recent opening up of the general Insurance sector to foreign companies, there is the prospect of two trends. New insurance product will be put out so expand business more is deepening than widening risk covered. The second trend would be to concentrate on urban middle and upper classes and settled jobholders with capacity to pay and with a perceived interest in good health of the family. Both trends make sound business sense in a vast growth market and would increase extensive hospital use and protection against huge hospitalization expenses, and promoted by urban private hospitals since their clientele will increase. Insurance is a welcome necessary step and must doubtless expand to help in facilitating equitable health care to shift to sections for which government is responsible. Indeed for those not able to access insurance it is government that will have to continue to provide the minimum services, and intervene against market failures including denial through adverse selection or moral hazard. Indeed in the long run the degree of inequity in health care after insurance systems are set up will depend ironically on the strength and delivery of the public system as a counterpoise in holding costs and relevance in technology. The insurable population in India has been assessed at 250 million and at an average of Rs 1000/- per person the premium amount per year would be Rs 25,000/- crores and is expected to treble in ten years- While the insurance product will dutifully reflect the demands of this colossal market and related technological developments in medicine, it should be required to extend beyond hospitalization and cover domiciliary treatment too in a big way; for instance, extending cover to ambulatory maternal and selected chronic conditions like Asthma more prevalent among the poor. The insurance regulatory authority has announced priority in licensing to companies set up with health insurance as key business and has emphasized the need for developing new products on fair terms to those at risk among the poor and in rural areas. Much will turn on what progress takes place through sound regulation covering aspects indicated below. In order to be socially relevant and commercially viable the scheme must aim at a proper mix of health hazards and cover many broad social classes and income groups. This is possible in poor locations or communities only if a group view is taken and on chat basis a population- based nsk is assessed and community rated premiums determined covering families for all common illnesses and based on epidemiological determined risk. In order that exclusions co-payments deductibles etc. remain minimum and relevant to our social situation, some well judged government merit subsidy can be incorporated into anti poverty family welfare or primary education or welfare pension schemes
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meant for old age. Innovative community based new products can be developed by using the scattered experience of such products for instance in SEWA, so that a minimum core cover can be developed as a model for innovative insurance by panchayats with reinsurance backup by companies and government bearing part of promotional costs. The bulk of the formal sector maybe covered by an expanded mandatory insurance with affordable cover and convenient modes of premium payment. Outside the formal manufacturing sector innovate schemes can be designed around specific occupation groups in the informal sector which are steadily becoming a base for old age pension entitlements, as in Kerala and Tamil Nadu - and brought under common risk rating. Finally, as in the West health insurance should develop influence and capacity as bulk purchaser or medical and hospital services to impact on quality and cost and provide greater understanding about Indian health and illness behaviours, patterns of utilization of care and intra family priorities for accessing medical care. Health insurance should be welcomed as a force for a fairer healthcare system. But its success should be judged on how well new products are developed with a cover beyond hospitalization, how fairly and inclusively the cover is offered and how far community rated premiums are established. The IRDA has an immense responsibility and with its leadership one can optimistically expect about 30% coverage by 2015 relieving the burden on the public systems. Health Perception & Plural Systems Health perceptions play an important part in ensuring sound health outcomes. To a large extent they are culturally determined but also subject to change with economic growth and social development. People intuitively develop capacity to make choices for being treated under the western of indigenous systems of medicines, keep a balance between good habits traditionally developed for healthy living and modem lifestyles, decide on where to go for chrome and acute care and how to apportion intra-family utilization of healthcare resources. The professional is generally bound by his discipline and its inherent logic of causation and effect and tends to discount even what work as successful practice, I fit does not fall within the accepted understanding of his profession. Some movement is occurring among eminent allopathic doctors trying, for instance, to rework Ayurveda theory in a modem idiom starting from respectful reverse analysis for actual successful contemporary practice of Ayurveda and provide a theoretical frame linking it to contemporary needs. There is evidence from public health campaigns in Tamil Nadu where every seventh person spontaneously expressed a preference for Sidda Medicine. Homeopathy for chronic ailment is widely accepted. The herbal base for Ayurveda medicine widely practiced in the Himalayan belt has down world attention a huge export market remains to be tapped according to the knowledgeable trade sources but the danger of bio-privacy remains and legal enablement should be put in place soon that would fully expand on our rights under the WTO agreements. The
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draft national policy on ISIvIH has attempted to place these plural systems in a modem service delivery and research and education context, it has covered its natural resource base, traditional knowledge base and development of institutions to carry a national heritage forward. There is hope for the survival and growth of the sector only if it becomes an example of convergence between people's and planner's perceptions and ensures its relevance, accountability and affordability to contemporary illnesses and conditions. At the same time it is undeniable that there is much cross practice by ISM practitioners which usually include prescriptions we western medicine as part of indigenous treatment Appropriate regulation is needed to protect people from fraud and other dangers but the larger question is how to make the perceptions of the professionals and planners regarding indigenous system of medicine less ambivalent. The separate department for ISM&H should be able to bring about functional integration of ISM and western medicine in service delivery at PHC levels by 2005 whereby it will usher in a uniquely Indian system of care. Emerging Scenario What then can we conclude about the prospects of health care in India in 2020? An optimistic scenario will be premised on an average 8% rate of economic growth during this decade and 10% per annum thereafter- If so, what would be the major fall out in terms of results on the health scene? In the first place, longevity estimates can be considered along the following lines. China in 2000 had a life- expectancy at birth of 69 years (M) and 73(F) whereas India had respectively 60 (M) and 63 (F). More importantly, healthy life expectancy at birth in China was estimated in the World Health Report 2001 at 61 (M) and 63.3 (F) whereas in Indian figures were 53 (M) and 51.7 (F). If we look at the percentage of life expectancy years lost as a result of the disease burden and effectiveness of health care systems, Chinese men would have lost 11.6 years against Indian men losing 12.7 years. The corresponding figures are 13.2 for Chinese women and 17.5 for Indian women. Clearly, an integrated approach is necessary to deal with avoidable mortality and morbidity and preventive steps in public health are needed to bridge the gaps, especially in regard to the Indian women. Taking all the factors into consideration, longevity estimates around 20-25 could be around 70 years, perhaps, without any distinction between men and women. This leads us to the second question of the remaining disease burden in communicable and non-communicable diseases, the effective of interventions, such as, immunization and maternal care and the extent of vulnerability among some groups. These issues have been death with in detail earlier. Clearly an optimistic forecast would envisage success in polio, yaws, leprosy, kalazar t'ilaria and blindness. As regards TB it is possible to arrest further growth in absolute numbers by 2010 and thereafter to bring it to less than an million withm internationally accepted limits by 2020. With regard to Malaria, the
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incidence can be reduced by a third or even upto half within a decade. In that case, one can expect near freedom from Malaria from most of the countries by 2020. As regards AIDS, it looks unlikely that infection can be leveled of by 2007. The prognosis in regard to the future shape of HIV / AIDS is uncertain. However, it can be a feasible aim to reduce maternal mortality from the present 400 to 100 per lakh population by 2010 and achieve world standards by 2020. As regards child health and nutrition, it is possible to reach IMRV30 per thousand live births by 2010 in most parts of the country though in some areas, it may take a few years more. What is important is the chance of two thirds decline in moderate malnutrition, and abolition of serious malnutrition completely by 2015 in the case of Cancer, it is feasible to set up an integrated system for proper screening, early detection, self care and timely investigation and referral. In the matter of disease burden as a whole, it is feasible to attempt to reach standards comparable to china from 2010 onwards. Taking the third aspect viz fairness in financing of health care and reformed structure of health services, an optimistic forecast would be based on the fact that the full potential of the vast public health infrastructure would be fully realized by 2010. Its extension to urban areas would be moderated to the extent substantial private provision of health care is available in urban areas, concentrating on its sensible and effective regulation. A reasonably wide network of private voluntary health insurance cover would be available for the bulk of the employed population and there would be models of replicable community based health insurance available for the unorganized sector. As regards the private sector in medicine, it should be possible in the course of this decade to settle the public role of private medical practice - independent or institutional. For this purpose, more experiments are to be done for promoting public private partnerships, focusing on the issue of how to erect on the basis of shared public health outcome as the key basis for the partnership. A sensible mixture of external regulation and professional self-regulation can be device in the consultation with the profession to ensure competence, quality and accountability. The future of plural systems in medical understanding and evaluation of comparative levels of competence and reliability in different systems - a task in which, the separate department for Indian systems of medicine and homeopathy will play a leading role in inducting quality into the indigenous medical practices. The next issue relates to the desirable level of public expenditure towards health services. China devotes 4.5% to its G-DP as against India devoting 5.1%. but this hides the fact that in China, public expenditure constitutes 38% whereas in India, it is only 1S% of total health expenditure. An optimistic forecast would be that the level of public expenditure will be raised progressively such that about 30% of total health expenditure would be met out of public funds by progressively increasing the health budget in states and the central and charging user fees in appropriate cases. The figure mentioned would perhaps correspond
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to the proportion of the population which may still need assistance is social development. Finally it is proper to remember that health is at bottom an issue in justice. It is in this context that we should ask the question as to how far and in what way has politics been engaged m health care? The record is disappointing. Most health sector issues figuring in political debate are those that affect interest groups and seldom central to choices in health care policy. For instance conditions of service and reward systems for Government doctors have drawn much attention often based on inter service comparison of no wider interest. Inter-system problems of our plural medical care have drawn more attention from courts than from politics. Hospital management and strikes, poor working of the MCI and corruption in recognition of colleges, dramatic cases of spurious drug supply etc have been debated but there has been no sustained attention on such issues as why malaria recrudescence is so common in some parts of India or why complaints about absence of informed consent or frequent in testing on women, or on the variations in prices and availability of essential drugs or for combating epidemic attacks in deprived areas seldom draw attention. The far reaching recommendations made by the Hathi Committee report and or the Lentin Commission report, have been implemented patchily. The role to be assigned to private sector in medicine, the need for a good referral system or the irrationality in drug prescriptions and sue have seldom been the point of political debate. Indeed the lack luster progress of MNP over the Plans shows political disinterest and the only way for politics to become more salient to the health of the poor and the reduction of health inequalities is for a much greater transfer of public resources for provision and financing - as has happened in the West, not only in UK or Canada but in the US itself with a sizable outlay on Medicaid and Medicare.

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Research Objectives:Macro Objectives: • To find out the satisfaction level of the patients in the multi-specialty hospitals. • To find out the factors, why NRIs are attracted towards taking medical treatments in India. • To find out which kind of medical treatment is mostly preferred by the NRIs to take in India. Micro Objectives: • To make aware the administration department of the particular hospitals regarding acceptance of facilities and services provided by them to the patients. Nature of Research:•

Research will be descriptive and explorative in nature.

• Research will be done mainly to understand the satisfaction level of the patients and by this way can understands the competition and also need gaps so that better services can be develop.

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Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders to obtain health care. It also refers pejoratively to the practice of healthcare providers travelling internationally to deliver healthcare Medical tourism – the process of “leaving home” for treatments and care abroad or elsewhere domestically – is an emerging phenomenon in the health. Tourism: An Indian overview Tourism is the largest service industry in India, with a contribution of 6.23% to the national GDP and 8.78% of the total employment in India. India witnesses’ more than 5 million annual foreign tourist arrivals and 562 million domestic tourism visits. The tourism industry in India generated about US$100 billion in 2008 and that is expected to increase to US$275.5 billion by 2018 at a 9.4% annual growth rate. The Ministry of Tourism is the nodal agency for the development and promotion of tourism in India and maintains the "Incredible India" campaign. Tourism will expand greatly in future mainly due to the revolution that is taking place on both the demand and supply side. The changing population structure, improvement in living standard, more disposable income, fewer working hours and long leisure time, better educated people, ageing population and more curious youth in the developed as well as developing countries, all will fuel the tourism industry growth. The arrival of a large number of customers, better educated and more sophisticated, will compel the tourist industry to launch new products and brands and re-invents traditional markets. The established traditional destinations founded on sun-sea-sand products will have to reengineer their products. They must diversify and improve the criteria for destinations and qualities of their traditional offers. Alongside beach tourism, the tourism sector will register a steady development of new products based on natural rural business, leisure and art and culture. Thus the study of new markets and emerging markets and necessity of diversified products are the basis of our strategy, which can enhance and sustain, existing and capture new markets. It is India’s vastness that challenges the imagination: the sub-continent, 3200km (2000 miles) from the mountainous vastness of the Himalayas in the north to the
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tropical lushness of Kerala in the south, is home to one sixth of the world’s population, a diverse culture and an intoxicatingly rich history. Desert in Rajasthan, tropical forests in the north eastern states, arid mountains in the delta region of Maharashtra and Karnataka and vast fertile planes in northern states of Uttar Pradesh, Haryana etc are just some of the geographical diversity that can be observed. We have a wealth of archeological sites and historical monuments. Manpower costs in the Indian hotel industry are one of the lowest in the world. This provides better margins for any industry which relies on man power. One of the fascinations of India is the juxtaposition of old and new; centuries of history – from the pre-historic Indus civilization to the British Raj – rub shoulders with the computer age; and Bangalore's ‘Silicon Valley’ is as much a part of the world's largest democracy as the remotest village is. The Deloitte 2009 Survey of Health Care Consumers, a nationally representative, online survey of more than 3,000 Americans, found that outbound medical tourism is expected to experience explosive growth over the next three to five years. Consider the following: • Health care costs are increasing at eight percent per year – well above the Consumer Price Index (CPI), thus eating into corporate profits and household disposable income. • The safety and quality of care available in many offshore settings is no longer an issue: Organizations including the Joint Commission International (JCI) and others are accrediting these facilities. • Consumers are willing to travel to obtain care that is both safe and less costly. In fact, two in five survey respondents said they would be interested in pursuing treatment abroad if quality was comparable and the savings were 50 percent or more. • By contrast, inbound medical tourism and medical tourism across state lines will continue to be an interesting opportunity for specialty hubs with treatments unavailable elsewhere in the world or in a community setting.
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•

Medical Tourism: Consumers in Search of Value is Deloitte’s latest report about innovations that might be considered disruptive to some in the U.S. health care system. Recent reports spotlighting retail clinics, the medical home payment model and other innovations point to a common theme – CHANGE.

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History:-

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The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism. Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth century England, for example, medtrotters visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis. Description Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries. Medical tourists can come from anywhere in the First World, including Europe, the Middle East, Japan, the United States, and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care. An authority at the Harvard Business School recently stated that "medical tourism is promoted much more heavily in the United Kingdom than in the United States". A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in New Zealand, Costa Rica, Singapore, Hong Kong, Thailand, Cuba, Colombia, Philippines or India, a patient could feasibly have an operation the day after their arrival. Additionally, patients are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for
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about $5,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all inclusive and include only the surgeon fees associated with the procedure. According to an article by the University of Delaware publication, UDaily: The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heartvalve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the US costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the US runs about $1,250 in South Africa. Popular medical travel worldwide destinations include: Argentina, Brunei, Cuba, Colombia, Costa Rica, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, Tunisia and New Zealand. Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. According to the "Sociedad Boliviana de Cirugia Plastica y Reconstructiva", more than 70% of middle and upper class women in the country have had some form of plastic surgery. Colombia also provides advanced care in cardiovascular and transplant surgery. In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris". A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing, which is the practice of traveling abroad to undergo
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in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production However, perceptions of medical tourism are not always positive. In places like the US, which has high standards of quality, medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care. Health tourism providers have developed as intermediaries to unite potential medical tourists with provider hospitals and other organizations. Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return. Process  The typical process is as follows:  The person seeking medical treatment abroad contacts a medical tourism provider.  The provider usually requires the patient to provide a medical report, including the nature of ailment, local doctor’s opinion, medical history, and diagnosis, and may request additional information.  Certified medical doctors or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc., is discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy.  The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care.  Once the treatment is done, the patient can remain in the tourist destination or return home.

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International healthcare accreditation Because standards are important when it comes to health care, there are parallel issues around medical tourism, international healthcare accreditation, evidencebased medicine and quality assurance. In the United States, the best known accreditation group is the Joint Commission International (JCI). They have been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999 and are a trusted source for American medical tourists. Many international hospitals today see obtaining JCI accreditation as a way to attract American patients. In the UK and Hong Kong, the Trent International Accreditation Scheme is a key player. The different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill and intensity of their marketing. They also vary in terms of cost to hospitals and healthcare institutions making use of them. A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent. Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele and Trent for potential British and European clientele. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics. Other relevant organizations include:
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The Society for International Healthcare Accreditation (SOFIHA), a freeto-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same. The primary role of this organisation is to promote a safe hospital environment for patients. HealthCare Tourism International, the first US-based non-profit to accredit the non-clinical aspects of health tourism, such as language issues, business practices, and false or misleading advertising prevention. The group provides accreditation for all major groups involved in the health tourism industry including hotels, recovery facilities, and medical tourism booking agencies.
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•

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The United Kingdom Accreditation Forum (UKAF) is an established network of accreditation organisations with the intention of sharing experience good practice and new ideas around the methodology for accreditation programmes, covering issues such as developing healthcare quality standards, implementation of standards within healthcare organisations, assessment by peer review and exploration of the peer review techniques to include the recruitment, training, monitoring and evaluation of peer reviewers and the mechanisms for awards of accredited status to organisations. The International Medical Travel Association, (IMTA, based in Singapore), is a nonprofit association formed to help address quality standards, liability issues, continuity of care, and other issues. Medical Tourism Association, is a nonprofit association focusing on transparency in quality and pricing.

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Risks:Medical tourism carries some risks that locally-provided medical care does not. Some countries, such as India, Malaysia, or Thailand have very different infectious disease-related epidemiology to Europe and North America. Exposure to diseases without having built up natural immunity can be a hazard for weakened individuals, specifically with respect to gastrointestinal diseases (e.g. Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis. However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of considering any infectious disease, including HIV, TB, and typhoid, while there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West. The quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from US or European standards. However, JCI and Trent fulfill the role of accreditation by assessing the standards in the healthcare in the countries like India, China and Thailand. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility in a cramped airline cabin are a known risk factor for developing blood clots in the legs such as venous thrombosis or pulmonary embolus economy class syndrome. Other vacation
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activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing. To minimise these problems, medical tourism patients often combine their medical trips with vacation time set aside for rest and recovery in the destination country. Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients. Differences in healthcare provider standards around the world have been recognized by the World Health Organization, and in 2004 it launched the World Alliance for Patient Safety. This body assists hospitals and government around the world in setting patient safety policy and practices that can become particularly relevant when providing medical tourism services Legal issues:By traveling outside their home country for medical care, medical tourists may encounter unfamiliar ethical and legal issues. The limited nature of litigation in non-US countries is one reason for the lower cost of care overseas. While some countries currently presenting themselves as attractive medical tourism destinations provide some form of legal remedies for medical malpractice, these legal avenues may be unappealing to the medical tourist. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. Hospitals and/or doctors in some countries may be unable to pay the financial damages awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not possessing appropriate insurance cover and/or medical indemnity. However new insurance products are available that protect the patient should an alleged medical malpractice occur overseas. Ethical issues:There can be major ethical issues around medical tourism. For example, the illegal purchase of organs and tissues for transplantation has been alleged in countries such as India and China. Medical tourism may raise broader ethical issues for the countries in which it is promoted. For example in India, some argue that a "policy of 'medical tourism for the classes and health missions for the masses' will lead to a deepening of
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the inequities" already embedded in the health care system. In Thailand, in 2008 it was stated that, "Doctors in Thailand have become so busy with foreigners that Thai patients are having trouble getting care". MEDICAL TOURISM AS AN INDUSTRY Medical tourism can be broadly defined as provision of ‘cost effective’ private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public. In many developing countries it is being actively promoted by the government’s official policy. India’s National Health policy 2002, for example, says: “To capitalize till ion on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings”. The formulation draws from recommendations that the corporate sector has been making in India and specifically from the “Policy Framework for Reforms in Health Care”, drafted by the prime minister’s Advisory Council on Trade and Industry, headed by Mukesh Ambani and Kumaramangalam Birla. GROWTH OF THE MEDICAL TOURISM INDUSTRY The countries where medical tourism is being actively promoted include Greece, South Africa, Jordan, India, Malaysia, Philippines and Singapore. India is a recent entrant into medical tourism. According to a study by McKinsey and the Confederation of Indian Industry, medical tourism in India could become a $1 billion business by 2012. The report predicts that: “By 2012, if medical tourism were to reach 25 per cent of revenues of private up-market players, up to Rs 10,000 crore will be added to the revenues of these players”. The Indian government predicts that India’s $17-billion-a-year health-care industry could grow 13 per cent in each of the next six years, boosted by medical tourism, which industry watchers say is growing at 30 per cent annually. In India, the Apollo group alone has so far treated 95,000 international patients, many of whom are of Indian origin. Apollo has been a forerunner in medical tourism in India and attracts patients from Southeast Asia, Africa, and the Middle East. The group has tied up with hospitals in Mauritius, Tanzania,
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Bangladesh and Yemen besides running a hospital in Sri Lanka, and managing a hospital in Dubai. Another corporate group running a chain of hospitals, Escorts, claims it has doubled its number of overseas patients - from 675 in 2000 to nearly 1,200 this year. Recently, the Ruby Hospital in Kolkata signed a contract with the British insurance company, BUPA. The management hopes to get British patients from the queue in the National Health Services soon. Some estimates say that foreigners account for 10 to 12 per cent of all patients in top Mumbai hospitals despite roadblocks like poor aviation connectivity, poor road infrastructure and absence of uniform quality standards. Analysts say that as many as 150,000 medical tourists came to India last in the year 2004. However, the current market for medical tourism in India is mainly limited to patients from the Middle East and South Asian economies. Some claim that the industry would flourish even without Western medical tourists. Afro-Asian people spend as much as $20 billion a year on health care outside their countries – Nigerians alone spend an estimated $1 billion a year.

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Medical tourism in India has emerged as the fastest growing segment of tourism industry despite the global economic downturn. High cost of treatments in the developed countries, particularly the USA and UK, has been forcing patients from such regions to look for alternative and cost-effective destinations to get their treatments done. The Indian medical tourism industry is presently at a nascent stage, but has an enormous potential for future growth and development. Satisfaction Level of the Patients:The major purpose to come in India are social gathering, treatment and tourism. The findings suggest that patients are coming majorly for the cardiac diseases, orthopedic diseases and for gastro intestinal diseases. Most of the patients select the Hospital or Doctors on the bases of the advice of their relatives or friends and from web sites. The major attraction for the patients are doctor’s specialization and low treatment charges. Patients gave their first priority to the treatment, followed by financial expenses, hospitality and accommodation. Most of the patients are satisfied with the treatment and facilities available in the hospital. Majority of the patients show their eagerness to visit the same hospital again in the future if there will be any need arise. Current Scenario in Indian Tourism • Tourism is the largest service industry in India, with a contribution of 6.23% to the national GDP and 8.78% of the total employment in India. • India witnesses more than 5 million annual foreign tourist arrivals and 562 million domestic tourism visits. • The tourism industry in India generated about US$100 billion in 2008 and that is expected to increase to US$275.5 billion by 2018 at a 9.4% annual growth rate. • The Ministry of Tourism is the nodal agency for the development and promotion of tourism in India and maintains the "Incredible India" campaign. • According to World Travel and Tourism Council, India will be a tourism hotspot from 2009-2018, having the highest 10-year growth potential. • The Travel & Tourism Competitiveness Report 2007 ranked tourism in India 6th in terms of price competitiveness and 39th in terms of safety and security.
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• Despite short- and medium-term setbacks, such as shortage of hotel rooms, tourism revenues are expected to surge by 42% from 2007 to 2017. • India has a growing medical tourism sector. The 2010 Commonwealth Games in Delhi has significantly boosted tourism in India. Hill Stations:Several hill stations served as summer capitals of Indian provinces, princely states, or, in the case of Shimla, of British India itself. Since Indian Independence, the role of these hill stations as summer capitals has largely ended, but many hill stations remain popular summer resorts. Most famous hill stations are:
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Pachmarhi, Madhya Pradesh - It is also known as The Queen of Satpura. Araku, Andhra Pradesh Gulmarg, Srinagar and Laddakh in Jammu and Kashmir Darjeeling in West Bengal Munnar in Kerala Ooty and Kodaikanal in Tamil Nadu Shillong in Meghalaya Shimla, Kullu in Himachal Pradesh Nainital in Uttarakhand Gangtok in Sikkim Mussoorie in Uttarakhand

In addition to the bustling hill stations and summer capitals of yore, there are several serene and peaceful nature retreats and places of interest to visit for a nature lover. These range from the stunning moonscapes of Leh and Ladhak, to small, exclusive nature retreats such as Dunagiri, Binsar, Mukteshwar in the Himalayas, to rolling vistas of Western Ghats to numerous private retreats in the rolling hills of Kerala. Beaches:Elephants and camels rides are common on Indian beaches. Shown here is Havelock Island, part of the Andaman and Nicobar Islands India offers a wide range of tropical beaches with silver/golden sand to coral beaches of Lakshadweep. States like Kerala and Goa have exploited the potential of beaches to the fullest. However, there are a lot many unexploited beaches in the states of Andhra Pradesh, Gujarat, Maharastra, Tamil Nadu and Karnataka.
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These states have very high potential to be develop them as future destinations for prospective tourists. Some of the famous tourist beaches are:
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Beaches of Vizag, Andhra Pradesh Beaches of Puri, Orissa Beaches of Digha, West Bengal Beaches of Goa Kovalam Beach, Kerala Marina Beach, Chennai Beaches of Mahabalipuram Beaches in Mumbai Beaches of Diu Beaches of Midnapore, West Bengal Andaman and Nicobar Islands Lakshadweep Islands

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A Country Forever... A Story Forever With Tourism being one of the foremost avenues to put India on the global map, it is heartening to see that the Travel and Tourism Competitiveness Report of 2010 from the World Economic Forum, has ranked India as 11th in the Asia Pacific region and 62nd overall, moving up three places on the list of the world’s most attractive destinations. It also ranked 14th best tourist destination for its natural resources and 24th for its cultural resources, owing to many World Heritage sites, rich flora and fauna, and strong creative industry. The Indian tourism industry ranked 5th in long-term growth and the report also expects it to become the second largest employer in the world by the year 2019. The Tourism Ministry has claimed that tourism in India has already started showing signs of early recovery from the impact of global economic meltdown and in December 2010 tourist’s arrivals grew substantially by 21% registering a growth of over 8% over the arrivals in December 2007 which was actually a year of high growth. In spite of the global economic recession in 2008 and 2009, the Indian economy has continued to have good growth. India’s GDP in 2008-09 grew by 6.7%. During April-September, 2010 India’s GDP has seen a growth of 7%, whereas the global economy is estimated to have a negative growth in 2009. The quantum jump in Foreign Direct Investment (FDI) in the Hotel & Tourism sector in the year 2009 and 2010 is also indicative of the positive scenario. Indicating a turnaround, foreign tourist arrivals into the country grew by 21 percent in December 2010, over the corresponding month in 2009.

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Foreign Tourist Arrivals 2010

Estimates of foreign tourist’s arrivals (FTAs) and foreign exchange earnings (FEEs) are important indicators of the tourism sectors. FEEs in USD terms during the month of November 2010 were USD 1.2 billion as compared to USD 1 billion in November 2008. • FTAs during 2010 were 5.11 million with a growth rate of (-) 3.3% as compared to the FTAs of 5.28 million and growth rate of 4% during 2008.
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FTAs during the Month of December 2010 were 6.46 lakh as compared to FTAs of 5.34 lakh in December 2009 and 5.97 lakh in December 2008.

 Foreign Exchange Earnings 2010 • FEEs in Rupee terms during 2010 were Rs. 54960 crore as compared to Rs. 50730 crore in 2009 . • The growth rate in FEEs in Rupee terms during 2010 was 8.3% as compared to 2009, and 14.4% during 2009 as compared to 2008 . • In spite of the negative growth rate of 3.3% in FTAs, FEEs in rupee terms observed a positive growth rate of about 8% during 2010.

• FEEs during 2010 were USD 11.39 billion as compared to USD 11.75 billion during 2009.

 FTAs in January 2011 • FTAs during the month of January 2011 were 4.91 lakh as compared to FTAs of 4.22 lakh during the month of January 2010 and 5.12 lakh in January 2009.  FEEs in January 2010 • FEEs during the month of January 2011 were Rs. 5593 crore as compared to Rs. 4598 crore in January 2010 and Rs. 5438 crore in January 2009. Government Initiatives :Realizing that the true potential of tourism lies in responsible practices on both the demand and supply sides of the tourism chain, the Ministry of Tourism has
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adopted the ‘sustainable tourism’ route and incorporated it into the innovative Rural Tourism Project.

Projects and Sanctioned Budgets Development of tourism is primarily undertaken by the State Governments/Union Territory Administrations and the Ministry of Tourism provides financial assistance for tourism projects based on the proposals received from them subject to availability of funds and priority. The Tourism Ministry had sanctioned numerous projects across the nation for enhancing the tourism infrastructure; many of them were sanctioned during the year 2009. After the silicon rush India is now considered as the golden spot for treating patients mostly from the developed countries and far east for ailments and procedures of relatively high cost and complexity. India is also aggressively promoting medical tourism in the current years -and slowly now it is moving into a new area of "medical outsourcing," where subcontractors provide services to the overburdened medical care systems in western countries. India's National Health Policy declares that treatment of foreign patients is legally an "export" and deemed "eligible for all fiscal incentives extended to export earnings." Government and private sector studies in India estimate that medical tourism could bring between $1 billion and $2 billion US into the country by 2012. Going by the Statistics various studies it can be easily said that India would be the leader in medical tourism within the next decade if only it could improve the infrastructure and tour attractions.

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Medical tourism: A Global perspective Medical tourism happens when patients go to a different country for either urgent or elective medical procedures. This phenomenon is fast becoming a worldwide, multibillion-dollar industry. The reasons patients travel for treatment vary. Many medical tourists from the United States are seeking treatment at a quarter or sometimes even a 10th of the cost at home. From Canada, it is often people who are frustrated by long waiting times. From Great Britain, the patient can't wait for treatment by the National Health Service but also can't afford to see a physician in private practice. For others, becoming a medical tourist is a chance to combine a tropical vacation with elective or plastic surgery. And moreover patients are coming from poorer countries such as Bangladesh where treatment may not be available and going for surgery in European or western developed countries is expensive. Thailand While, so far, India has attracted patients from Europe, the Middle East and Canada, Thailand has been the goal for Americans. India initially attracted people who had left that country for the West; Thailand treated western expatriates across Southeast Asia. Many of them worked for western companies and had the advantage of flexible, worldwide medical insurance plans geared specifically at the expatriate and overseas corporate markets. With the growth of medical-related travel and aggressive marketing, Bangkok became a centre for medical tourism. Bangkok's International Medical Centre offers services in 26 languages, recognizes cultural and religious dietary restrictions and has a special wing for Japanese patients The medical tour companies that serve Thailand often put emphasis on the vacation aspects, offering post-recovery resort stays South Africa South Africa also draws many cosmetic surgery patients, especially from Europe, and many South African clinics offer packages that include personal assistants, visits with trained therapists, trips to top beauty salons, post-operative care in luxury hotels and safaris or other vacation incentives. Because the South African rand has such a longstanding low rate on the foreign-exchange market, medical tourism packages there tend to be perpetual bargains as well.
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Argentina Argentina ranks high for plastic surgery, and Hungary draws large numbers of patients from Western Europe and the U.S. for high-quality cosmetic and dental procedures that cost half of what they would in Germany and America. Dubai Lastly, Dubai--a destination already known as a luxury vacation paradise--is scheduled to open the Dubai Healthcare City by 2010. Situated on the Red Sea, this clinic will be the largest international medical center between Europe and Southeast Asia. Slated to include a new branch of the Harvard Medical School, it also may be the most prestigious foreign clinic on the horizon. Other countries Other countries interested in medical tourism tended to start offering care to specific markets but have expanded their services as the demand grows around the world. Cuba, for example, first aimed its services at well-off patients from Central and South America and now attracts patients from Canada, Germany and Italy. Malaysia attracts patients from surrounding Southeast Asian countries; Jordan serves patients from the Middle East. Israel caters to both Jewish patients and people from some nearby countries. One Israeli hospital advertises worldwide services, specializing in both male and female infertility, in-vitro fertilization and high-risk pregnancies. South Africa offers package medical holiday deals with stays at either luxury hotels or safaris.

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STRENGTHS:
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Low cost surgeries and medical treatments such as complex Bone Marrow transplant, liver transplant, kidney transplant, specialized cardiac/heart surgery, surgeries for hip joint replacement, knee joint replacement, dental surgery, and cosmetic surgeries, to mention a few. All these surgical procedures are carried out by expert doctors. India has various state-of-the-art medical institutes and hospitals of international standards. People all around the world are eager to see the diversity and unity of India. So, when they get the advantage of medical treatment along with a dual advantage of getting to travel India, they choose India over others. Comparatively the cost of surgery in India is estimated to be one-tenth of that in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly there are other such surgical procedures that cost less in India. Chennai (formerly known as Madras), the capital city of the Indian state of Tamil Nadu, has been declared India's Health Capital, as it nets in 48% of health tourists from abroad and 37-41% of domestic health tourists.

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WEAKNESSES: • Lack of adequate infrastructure is the biggest problem that India faces. The aviation industry in India, for example, is inefficient and does not provide even the basic facilities at airports. The road condition in India is very worse. The population has grown exponentially since 1947 but we still use the same rail system constructed by the British. • The government spends next to nothing on proper marketing of India’s tourism abroad. As a result foreigners still think of India as a country ridden by poverty, superstition, and diseases with snake charmers and sadhus at every nook and cranny.
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Case in point Thailand; where in spite of the huge problem of bird flu disease the tourists arrival only dropped by less than 15% where as in India when cases of plague started occurring in Surat in 1994 the arrival of foreign tourists in India decreased by almost 36%
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OPPORTUNITIES: • More proactive role from the government of India in terms of framing policies. • Allowing entry of more multinational companies into the country giving us a global perspective. • Growth of domestic tourism. • The advantage here is that domestic tourism and international tourism can be segregated easily owing to the different in the period of holidays. THREATS:
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Political turbulence within India in Kashmir and Gujarat has also reduced tourist traffic. Not only is that fear of epidemics such as for malaria, cholera, dengue, plague etc foremost in the mind of European and America patients.

• Aggressive strategies adopted by other countries like Australia, Singapore in promoting tourism are also not helping.

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Besides being the land of Taj, a land of diverse cultures, a land of tradition, a land of highly developed spiritualism, India can also be called the land of healing for the ailing. Contemporary India is a forerunner in providing healthcare facilities for all kinds and type of patients. This has been possible largely because of the professionalism that has crept in to the healthcare sector. The credit for this goes wholly to the private sector. Also as a result of this the medical help in India is now comparable to the best in the world. India provides a long list of various facilities like world class hospitals, state-of art technology, competent doctors, professional management, top quality nurse and paramedical staff and all this with an icing of comparatively lower prices making it economical as well. More and more people are realizing that India is the right place for top quality and economically affordable treatments. It is also reliable and can be regarded as one of the best in the world. As far as India is concerned price factor is the major advantage. It has been taken into account that the cost of getting treated in India is almost 10% and in some cases 80- 90% cheaper than what it costs in the developed countries. This becomes very evident when you notice the average the Indian cost of a cardiac surgery and Compare it with the average US cost. This coupled with the fact that cardiac surgery in India has a success rate of 98.5% which is comparable to the best institutions in the world. This is certainly a major benefit. Hospitals in the major metros of India have already recorded a 12% international patient flow. These patients are mainly from the neighboring South East Asian countries. And these figures will be growing in the near future. India can catch up by the medical travelers for specific medical treatments as well as for regular medical checkups. Most of the hospitals are centrally located in the major Indian cities, are easily accessible and are capable of looking after the patients with best care. This was in regards with urban medi-care but rural India also runs back to back. It may not have world class infrastructure but the medical attention is prompt with competent doctors even in the remotest parts of the country. For those who plan to get a regular medical checkup done, India is the ideal the place to be. With its numerous attractions one can come here with the family and combine the health check up with a pleasure trip for the family. All this is because of the enormous growth witnessed by the private sector. It was very modest in the early stages and has now become a flourishing industry with the most modern state-of-art technology at its disposal. It is estimated that
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75-80% of the healthcare services and investments in India are now provided by the private sector. An added advantage that India has is that it has one of the largest congregations of pharmaceutical companies in the whole world. It is self-sufficient in drug production and exports drugs to more than 180 countries. The privatization of this sector has brought with it facilities of the star categories & world class treatments. The country now boasts a number of corporate hospitals. India is a market for professionals in the medical field for most of the renowned hospitals in the whole world. Hi-tech medical facilities have become a necessity following the consumer demand among the world’s fastest growing middle-class masses. India offers at its own doorsteps a range of world quality hospitals and treatments at a fraction of world costs with comparable success rate and service levels directly in proportion to the high value system and natural caring that comes along with its traditional heritage. Indian hospitals are now being acclaimed the world over for the standards of healthcare delivery. The country boasts of superior technology with skilled super specialists along with sound infrastructure & professional outlook. Major hospitals in Chennai, Mumbai, Hyderabad & New Delhi have recorded a 125 patient flow from the neighboring & South-East Asian countries. This is because people have realized that they can now have access to international quality medi-care at 10% of international costs in India. Technologies of the new millennium including ECG through conferencing will soon be introduced in India, making it feasible for doctors to benefit from the advice of other experts. Indian doctors performed the country’s first robotic heart surgery which reduces the risk and trauma associated with critical conditions. Apart from that India has also become an important destination for medical conferences. Major international medical conferences on ophthalmology, oral cancer, etc. were held in India with many more on the anvil. International Conference An international health and medical tourism conference is slated to be held towards the end of this year at Bangalore, which will see delegates from various South- East Asian countries, the Middle-East and even Africa participating. This will serve as an ideal platform for Incredible India to market its health and medical tourism products and services.

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INDIAN HEALTHCARE SPECIALTIES Cardiac Care Cardiac care has become a speciality in India with names such as the Escorts Heart Institute, AIIMS and Apollo hospitals becoming names to reckon with. They combine the latest innovations in medical electronics with unmatched expertise in leading Cardio logistics and cardio-thoracic surgeons. These centers have the distinction of providing comprehensive cardiac care spanning from basic facilities in preventive cardiology to the more sophisticated curative technology. The technology is contemporary and world class and the volumes handled match global benchmarks. They also specialize in offering surgery to high risk patients with the introduction of innovative techniques of minimally invasive and robotic surgeries. The success rates here at these hospitals in India are at an average of 98.5% which are at par with the leading cardiac centers around the world. They are in possession of cardiac care units with sophisticated equipments and investigate facilities like echocardiography with colored Doppler, Nuclear scanning and Coronary Angiography. Dialysis and kidney transplant Common diseases like Diabetes, Hypertension and Chronic GlomeruloNephritis can lead to permanent loss of renal function with Dialysis and renal transplantation being the frequent outcome. The emergence of new therapeutic interventions has created opportunities in India to manage the progression of renal diseases. For those who need replacement therapy, services like Hemodialysis, Chronic Ambulatory peritoneal dialysis (CAPD), and transplantation are also available. Patients can also avail of the Bicarbonate Dialysis facilities. The cost of getting a dialysis is around Rs.1700-1800 per dialysis. Similarly a Kidney transplant package in India is available for around Rs.3 lakh. Neurosurgery & Trauma surgery Other routine procedures performed with excellent results are replacement Arthroplasties, Diagnostics and Operative Arthroscopy, spinal surgery including Harrington rod instrumentation, corrective and reconstructive procedure for poliomyelitis and cerebral palsy.
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In addition the advanced Luque technique is employed for the correction of complex scoliosis and decompression and stabilization of fractures of dorsal and lumbar spine by neurosurgeon with excellent training and background. Some super speciality hospitals in India like AIIMS, Ram Manohar Lohia hospital, Bombay hospital, Jaslok hospital and Apollo hospitals have advanced facilities dedicated to the treatment of entire range of brain and spinal disorders with highly experienced neurosurgeons, neurologists and neuro-anaesthetists. Joint replacement surgery Shoulder/ hip replacement and bilateral knee replacement surgery using the most advanced keyhole or endoscopic surgery and anthroscopy is done at several hospitals in India including the Apollo hospital, Delhi; Bombay hospital, Mumbai and Madras Institute of Orthopedics and Trauma Sciences. Some hospitals like Apollo in Delhi have operation theatres with laminar air flow system. A knee joint replacement costs about Rs.2 and a half lakhs in India. Refractive surgery This type of surgery is gaining popularity in India both among the public as well as the opthalmogistis. Till a few years ago only a few centers performed high volume radial keratotomy. Today, the highest international quality of eye care for cornea, cataract, squin and glaucoma is available in over 40 centers all over India. When it comes to reliability India has the best ophthalmic surgeons with clinic-academic expertise honed to perfection in the best possible institutions. The no stitch cataract surgery with the most modern way of removing cataracts through the use of phacoemulsification procedure can be performed in India for as little as Rs.20000 for both the eyes. Facilities for PRK, Myopia and astigmatism are now available in almost all parts of the country. Hyperopic and LASIK are available and even supra-hard cataracts are treated using just 1mm instead of 3mm incision size. Nuclear medicine This is now common place, as it involves use of radioactive isotopes in very small doses in diagnosing and treatment of diseases, radioactive medicine is injected or administered orally and the distribution in the organ is scanned using a gamma camera.
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Various non cardiac planar/SPECT studies for bone, thyroid, liver and lung scanning functions are performed at specialized centers in India. Cosmetic surgery A new dimension of the medical field taking off in India is the cosmetic surgery which utilizes some of the latest techniques in corrective procedures. Some disfigurations corrected include hair restoration, rhinoplasties, stalling of aging process, dermabrasions, otoplasty for protruding ears, chin and cheek enlargement, lip reductions, various types of breast surgeries and reconstructions and liposuction. Non invasive surgical procedures like streotactic radio surgery and radiotherapy for brain tumors are practiced successfully. AYURVEDA:India has a rich heritage in the areas of traditional and natural medicines. The earliest mention of Indian medical practices can be found in the Vedas and Samhitas of Charaka, Bhela and Shusruta. A systematic and scientific approach was adopted by the sages of the time leading to the development of a system that is relevant even today. India is the land of Ayurveda. It believes in removing the cause of illness and not just curing the disease itself. It is based on herbals and herbal components without having side effects. Ayurveda considers that the base of life lies in the five primary elements; ether (space), air, fire, water and earth. And the individual is made up of a unique proportion of the five elements in unique combinations to form three doshas (vata, pita and kapha). When any of these doshas become accute, a person falls ill. Ayurveda recommends a special life style and nutritional guidelines supplemented with herbal medicines. If toxins are abundant, then a cleaning process known as Panchkarma is recommended to eliminate those unwanted toxins and revitalize both mind and body. Ayurveda offers treatments for ailments such as arthritis, paralysis, obesity, sinusitis, migraine, premature aging and general health care. Kerala is a world tourist destination and part of the reasons lies with the well- known stress-releasing therapies of famed Ayurvedic research centers. The climate along with the blessing of nature has turned Kerala into the ideal place for ayurvedic, curative and rejuvenating treatments
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HYDROTHERAPY Hydrotherapy, or water therapy as it is also known centres around (as you've probably guessed) the use of water as a healing agent. The buoyancy, viscosity and mineral components of water are used through hydrotherapy to heal or relieve ills as varied as fatigue, sore throats, and colds, inflammation of the joints, jaundice, rheumatism, arthritis, spondylitis, insomnia, soft tissue injuries and even diabetes. As an alternative system of healing, hydrotherapy is one of the oldest, safest and cheapest- which is definitely part of the reason why it's swiftly gaining in popularity. Hydrotherapy is no upstart; it's been around for more than 5,000 years, when the first mineral and thermal baths appeared in Greece. The Greeks, however, were not the only people to realize the healing powers of water. They were followed in their appreciation of the therapeutic liquid by the Romans (who are credited with having set up well-planned baths all across their empire); the Egyptians, the Japanese and the native Indian Americans. Most modern techniques borrow from both Eastern and Western forms of water therapy, and span a vast range of treatments. Basically, hydrotherapy is instrumental in stimulating blood circulation, increasing the production of stress hormones, improving the immune system and lessening pain sensitivity. The most common curative methods used in hydrotherapy include: Cold Baths: Cold baths are used mainly as a means of stimulating blood circulation, and are also used for reducing swelling. Steam Baths: Hot steam helps encourage sweating, which in turn opens the skin's pores, leaving the individual feeling refreshed and rejuvenated. It's not specifically healing, but it works wonders if you're feeling tired and drained, and can be an effective means of detoxification. Neutral Baths: A neutral bath-as the name suggests- uses water that is neither hotter nor colder than the temperature of the human body (cold or hot water draws or transmits heat to or from the body, as the case may be). For a neutral bath, the individual is immersed in water that is maintained at a steady temperature of between 33.5°C and 35.6, for about half an hour. This has a sedative, and even soporific, effect on the patient and is used to calm the nervous system.
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Floatation: As relaxing and refreshing as a neutral bath, floatation involves lying face up in a dark, enclosed tank of warm, heavily salted water. Hot and Cold Sprays: High-pressure spray jets of hot or cold water are used to heal or relieve a number of minor ailments, and mainly to stimulate organ function, the nervous system and the immune system. Hot and Cold Compresses: Both hot as well as cold compresses actually start off as cold compresses- a cloth dipped in ice-cold water and left on the effected part of the body for a certain period of time. In the case of a cold compress, the pack is replaced by an equally cold pack once it begins to lose its chill. In the case of a hot compress, the pack is left on and allowed to heat up by the warmth of the body. Both types of compresses are used in various ways, especially to treat acute injuries. Ice Packs: Ice packs- which contain crushed ice or a special gel- are applied to the body to reduce swelling, pain and inflammation. Wet Sheet Packs: A wet sheet pack (also known as bodies wrap) is, as the name suggests, a procedure in which the entire body is wrapped in a cold, wet sheet that is in turn covered with a woolen blanket. The sheet is left in place until it dries by the warmth of the body (usually about half an hour to relieve a fever; longer to relax and soothe the body; or up to 3 hours to induce sweating, which can be a good detoxification method for those with drinking or smoking problems). Among the spas in India that offer hydrotherapy treatments are:       Ananda in the Himalayas Tehri Garhwal (Uttaranchal) Spa Aguada Goa Angsana Oasis Spa and Resort Bangalore The Leela Palace Bangalore Golden Palms Spa and Resort Bangalore

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YOGA:If Ayurveda is the science of body, yoga is the science of the mind. Practiced together they can go a long way in making an individual fit. The word yoga means to join together. The ultimate aim of yoga is to unite the human soul with the universal spirit. Yoga was developed 5000 years ago and the base of yoga is described in the Yoga Sutra of Patanjali. This describes eight stages of yoga. These are Yam (universal moral commands), Niyam (self purification), Asana (posture), Pranayama (breathing control), Prathyahara (withdrawal of mind from external objects), Dharana (concentration), Dhyana (meditation), and Samadhi (state of super consciousness). To get the benefits of yoga, one has to practice Asana, Pranayama and Yoganidra. With the regular practice of asanas one can 327 control cholesterol level, reduce weight, normalize blood pressure and improve cardiac performance. Pranayama helps to release tensions, develop relaxed state of mind and Yoganidra is a form of meditation that relaxes both physiological and psychological systems. Today, yoga has become popular in India and abroad and in a number of places including urban and rural areas yoga is taught and practiced. SPA - TREATMENT:Most of the other parts of the world have their own therapies and treatment that are no doubt effective in restoring wellness and beauty. New kinds of health tours that are gaining popularity in India are spa tours. Spas offer the unique advantages of taking the best from the west and the east combining them with the indigenous system and offering best of the two worlds. In hydropathy, Swedish massages work with the Javanese Mandy, lulur, aromatherapy, reflexology and traditional ayurveda procedures to help keep the tourist healthy and enhance beauty. Combining these therapies with meditation, yoga and pranayama make the spa experience in India a new destination for medical tourism. The spas are very useful for controlling blood pressure, insomnia, cure tension, depression, paralysis and number of other deadly diseases. Ananda Resort in Rishikesh, Angsana Resort, Golden Palm Spa and Ayurgram in
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Bangalore offer ayurveda, naturopathy, yoga and meditation packages. (Gaur Kanchilal) Allopathy India has made rapid strides in advanced health care systems, which provides worldclass allopathic treatment. This has become possible because of the emergence of the private sector in a big way in this field. More and more foreign tourists are realizing that India is an ideal place for stopover treatment. Indian Multi-specialty hospitals are providing worldclass treatment at an amazingly economical cost as compared to the west. Quality services and low price factor primarily go in favour of India. The cardio care, bone marrow transplantation, dialysis, kidney transplant, neuron–surgery, joint replacement surgery, urology, osteoporosis and numerous diseases are treated at Indian hospitals with full professional expertise. Apollo hospital group, Escorts in Delhi, Jason Hospital, Global Hospital, and Max Health Care are catering to medical care for international patients in the areas of diagnostic, disease management, preventive health care and incisive surgeries. The tourism department has devised websites in order to provide information. Many Ayurveda health resorts that are owned by traditional Ayurveda Institutes have come up. Ayurgram is a novel concept that not only offers heritage accommodation but also offers a whole range of Ayurvedic treatments and rejuvenating packages.

SPIRITUAL TOURISM:Globally people are increasingly mentally disturbed and looking for solace in spiritual reading, meditation and moments of divine ecstasy. Our country has been known as the seat of spiritualism and India’s cosmopolitan nature is best reflected in its pilgrim centres. Religion is the life-blood for followers of major religion and sects. Hinduism, Islam, Buddhism, Jainism, Zoroastrianism and Christianity have lived here for centuries. The visible outpouring of religious fervor is witnessed in the architecturally lavish temples, mosques, monasteries and Churches spreads across the length and breadth of the country. India is not only known as a place rich in its culture with varied attractions but also for many places of worship, present itself as embodiments of compassion where one get peace of mind. Thus India has been respected as a destination for spiritual tourism for domestic and international tourists. Spiritual tourism is also termed as religious heritage tourism. It includes all the religions mentioned above; religious places associated with,
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emotional attachment to these centers and infrastructure facilities for the tourists. This can also be referred to as pilgrimage tourism, as clients are not looking for luxury but arduous journeys to meet the divine goal or simple life. ADVENTURE TOURISM:Youth tourism has been identified as one of the largest segments of global and domestic tourism. The young travelers are primarily experience seekers, collecting, enquiring unique experiences. Adventure and risk have a special role to play in the behavior and attitudes of young travelers. The growing number of young travelers is being fuelled by a number of factors such as increased participation in higher education, falling level of youth unemployment, increased travel budget through parental contribution, search for an even more exciting and unique experience and cheaper long distance travel. Youth and adventure tourism appears to have considerable growth potential. The rising income in some major potential source markets such as the Central and Eastern Europe, Asia and Latin America, combined with the lower travel cost, growing student populations around the world particularly in developing countries, has fuelled the demand. India: a heaven for adventure tourism India has been an attraction for travelers from all over the world. Though in the field of international tourism, the segment of adventure tourism in India is getting only a fraction of such traffic. The trend has been showing an increased movement year after year with the development of facilities and greater awareness about adventure tourism options. RURAL TOURISM:Rural tourism has been identified as one of the priority areas for development of Indian tourism. Rural tourism experience should be attractive to the tourists and sustainable for the host community. The Ninth Plan identified basic objectives of rural tourism as: • Improve the quality of life of rural people • Provide good experience to the tourist • Maintain the quality of environment. Indian villages have the potential for tourism development. With attractive and unique traditional way of life, rich culture, nature, crafts, folk-lore and livelihood of Indian villages are a promising destination for the tourist. It also
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provides tourism facilities in terms of accessibility, accommodation, sanitation and security. Rural tourism can be used as a means to:• Improve the well being of the rural poor • Empower the rural people • Empower the women • Enhance the rural infrastructure • Participate in decision-making and implementing tourism policies • Interaction with the outside world • Improve the social condition of lower sections of the society. • Protection of culture, heritage, and nature. To tap the immense opportunities, coordinated actives of all agencies involved in the development are required. A carefully planned and properly implemented development will definitely benefit the community economically and improve the quality of life in the villages. The success of such development depends upon the people’s participation at grass root level for the development of tourist facilities and for creating a tourist friendly atmosphere. Development of rural tourism is fast and trade in hotels and restaurants is growing rapidly. Increase in the share of earnings through rural tourism will no doubt; provide an attractive means of livelihood to the poor rural community. It increases the purchasing power at all levels of community and strengthens the rural economy. Development of infrastructure facilities such as rail, electricity, water, health and sanitation will definitely improve the quality of life.

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Why the world is moving towards medical tourism? Medical tourists have good cause to seek out care beyond the United States for many reasons. In some regions of the world, state-of-the-art medical facilities are hard to come by, if they exist at all; in other countries, the public health-care system is so overburdened that it can take years to get needed care. In Britain and Canada, for instance, the waiting period for a hip replacement can be a year or more, while in Bangkok or Bangalore, a patient can be in the operating room the morning after getting off a plane. For many medical tourists, though, the real attraction is price. The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the U.S., for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $1,250 in South Africa. The savings sound very attractive, but a good new hip and a nice new face don’t seem like the sort of things anyone would want to bargain with. How does the balance of savings versus risk pay off in terms of success rates. Inferior medical care would not be worth having at any price, and some skeptics warn that Third World surgery cannot possibly be as good as that available in the United States. In fact, there have been cases of botched plastic surgery, particularly from Mexican clinics in the days before anyone figured out what a gold mine cheap, high quality care could be for the developing countries.

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Trends in medical tourism in the near future:Some important trends guarantee that the market for medical tourism will continue to expand in the years ahead. By 2015, the health of the vast Baby Boom generation will have begun its slow, final decline, and, with more than 220 million Boomers in the United States, Canada, Europe, Australia and New Zealand, this represents a significant market for inexpensive, high-quality medical care. Medical tourism will be particularly attractive in the United States, where an estimated 43 million people are without health insurance and 120 million without dental coverage--numbers that are both likely to grow. Patients in Britain, Canada and other countries with long waiting lists for major surgery will be just as eager to take advantage of foreign health-care options.

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Though the service sector has considerable contribution in India’s GDP, it is negligible on the export front with only around 25 per cent of total export. Value added services generally exceed 60 per cent of total output in the high income industrialized economy. In the global scenario, India’s share of services export is only 1.3 per cent (2003) i.e. USD 20.7 billion which has gone up from 0.57 per cent (1990). Overall service export growth rate in India is 8 per cent (2002) against a global growth rate of 5 per cent. It had a tremendous impact on India’s Forex reserve. Forex reserve rise to USD 118.628 on May, 2004 in comparison to USD 79.22 for the same period in 2003. Being a service sector member, medical and tourism services export can further rise India’s Forex Reserve along with a major contribution from software exports. In India, international tourist rose 15.3 per cent between January and December, 2003. Though tourism and travel industry contribution is 2.5 per cent to our countries GDP (international ranking 124) but recent initiative from the government like liberalized open sky policy to increase flight capacity, lower and attractive fares, increase in hotel room capacity by nearly 80 per cent (from 2000) and better connectivity between major tourist destination (Express Highway project) has helped India to rank among the top five international holiday destination when independent traveler conducted a poll in 134 countries. Healthcare industry has shown considerable growth in last few years. Emergence of top notch corporate hospitals and continuous effort for improvement of quality of care has placed Indian private healthcare in a respectable position on the global map. High ratio of foreign qualified medical practitioners and well-trained nursing and paramedical staff have developed confidence amongst the people who are seeking medical care from Indian Hospitals.

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There are several characteristics that make India an appealing destination for visitors seeking health services. These include its well-trained health practitioners; a large populace of good English speaking doctors, guides and medical staff; availability of super-specialty centers that excel in cardiology and cardio-thoracic surgery, joint replacements, transplants, cosmetic treatments, dental care, orthopedic surgery and more; hospitals that provide the full gamut of health services which include full body pathology, comprehensive physical and gynecological examinations, echo Doppler, high strength MRI etc. using latest, technologically advanced diagnostic equipments; and finally, and more importantly the availability of these premium services at prices that are extremely reasonable for the foreign tourist. PROMOTION OF MEDICAL TOURISM The key “selling points” of the medical tourism industry are its “cost effectiveness” and its combination with the attractions of tourism. The latter also uses the ploy of selling the “exotica” of the countries involved as well as the packaging of health care with traditional therapies and treatment methods. Price advantage is, of course, a major selling point. The slogan, thus is, “First World treatment’ at Third World prices”. The cost differential across the board is huge: only a tenth and sometimes even a sixteenth of the cost in the West. Open-heart surgery could cost up to $70,000 in Britain and up to $150,000 in the US; in India’s best hospitals it could cost between $3,000 and $10,000. Knee surgery (on both knees) costs 350,000 rupees ($7,700) in India; in Britain this costs £10,000 ($16,950), more than twice as much. Dental, eye and cosmetic surgeries in Western countries cost three to four times as much as in India. The price advantage is however offset today for patients from the developed countries by concerns regarding standards, insurance coverage and other infrastructure. This is where the tourism and medical industries are trying to pool resources, and also putting pressure on the government. We shall turn to their implications later. In India the strong tradition of traditional systems of health care in Kerala, for example, is utilized. Kerala Ayurveda centres have been established at multiple locations in various metro cities, thus highlighting the advantages of Ayurveda in health management. The health tourism focus has seen Kerala participate in
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various trade shows and expos wherein the advantages of this traditional form of medicine are showcased. A generic problem with medical tourism is that it reinforces the medicalised view of health care. By promoting the notion that medical services can be bought off the shelf from the lowest priced provider anywhere in the globe, it also takes away the pressure from the government to provide comprehensive health care to all its citizens. It is a deepening of the whole notion of health care that is being pushed today which emphasizes on technology and private enterprise. The important question here is for whom is ‘cost effective’ services to be provided. Clearly the services are “cost effective” for those who can pay and in addition come from countries where medical care costs are exorbitant - because of the failure of the government to provide affordable medical care. It thus attracts only a small fraction that can pay for medical care and leaves out large sections that are denied medical care but cannot afford to pay. The demand for cost effective specialized care is coming from the developed countries where there has been a decline in public spending and rise in life expectancy and noncommunicable diseases that requires specialist services. KERALA - THE PIONEER STATE Kerala, or God’s Own Country as its corporate slogan goes, has pioneered health and medical tourism in India. They have made a concerted effort to promote health tourism in a big way, which has resulted in a substantial increase of visitor arrivals into the state. Kerala and Ayurveda have virtually become synonymous with each other. However, though Kerala has strongly focused on Ayurveda and its wide array of treatments and medications, good facilities are also available in the other traditional forms of medicine as well as in modern medical treatment. The bias towards health tourism in Kerala is so strong that Kerala Ayurveda Centres have been established at multiple locations in various metro cities, thus highlighting the advantages of Ayurveda in health management. The health tourism focus has seen Kerala participate in various trade shows and expos wherein the advantages of this traditional form of medicine are showcased. Medical Tourism in Kerala • Kerala is already marketed as a health destination mainly for its Ayurveda Packages.
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• Medical tourism is marketed along with ayurveda and to her health packages. • Major hospitals like KIMS, Trivandrum, Lake Shore and AIMS in Kochi, and MIMS, Calicut have pioneered joining hands with the Government promoting Medical Tourism. • Globalization and economic liberalization have given a boost to the specialized Medical Service Sector • Health Insurance Companies are playing a major role in Medical Tourism.

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Kerala pioneered health and medical tourism in India through Ayurveda and other Medical Tourism Product

• Medical tourism is like any leisure product where service components like airlines, hotels, travel companies, transportation, food outlets are offered and medical treatment at the best hospitals • The medical treatments for various ailments are packaged with recuperative leisure packages at world class tourist resorts.
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Kerala a Medical Tourism Destination is well connected by Air from major medical tourism markets in the Middle East, European markets and South Asia

• Moderate weather throughout the year
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• Advanced and sophisticated hospitals of International standards located in Kerala. • Renowned doctors specialized in almost all major disciplines. • Trained paramedical staff and technicians available in Kerala • Easier communication with majority English speaking public • The higher hygienic standards of Kerala • The developed tourism industry in Kerala with its array of high quality resorts and for an excellent recuperative holiday by tour operators joining or packages of medical treatment and surgery.
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Medical tourism packages offered and market hands with excellent hospitals incredibly competitive cost compared to other countries honoring of medical insurance by hospitals in Kerala.

• Marketed efficiently in source markets
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Distributed widely and brought to the doorstep industry made it easy for the patients. The Department of Tourism, Kerala pioneers the tourism destination in the International market.

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• Medical history • Patient received at the airport, an escort • Transferred to a hotel or resort. • Escort takes the patient to the hotel and into the hospital. Emerging Trends of Medical Tourism in India

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Medical tourism was a silver lining for those millions of Uninsured, underinsured and those who were forced to postpone treatments due to long waiting lists. What seemed like a boon to patients from Western countries like US, UK and Canada is now a twilight of hope for those countries who are deemed as Medical Tourism hubs. In popular medical tourism destinations like India, Singapore and Thailand, Medical Tourism is a fast growing industry where millions of dollars are being pumped in rigorously. In order to cope with the growing demand for medical care, hospitals, medical practitioners and even governments have taken measures to promote health care in India. When it comes to health care, safety is the foremost concern. The hospitals in India are well equipped with the latest technology and houses highly qualified and experienced staff who can provide timely and quality medical treatment to patients. As a move in promoting medical tourism, many hospitals are deemed as “corporate hospitals” that specially cater to the needs of medical tourists in India. Apart from offering world class treatments, they offer various services that make medical tourists’ stay in India hassle free. Many hospitals in India have international accreditations that certify the quality of health care service. Indian Government has acknowledged the growth of medical tourism in India and is now offering Medical Visas. The initial period for a medical visa may be up to a period of one year or the period of treatment whichever less, which can be extended for a further period up to one year be the State Government/ FRROs on the production of medical certificate/ advice from the reputed/ recognized/ specialized hospitals in the country. Any further extension will be granted by the Ministry of Home Affairs only on the recommendations of the State Government/ FRROs supported by appropriate Medical documents. Such visa will be valid for maximum three entries during one year. India is a big player in the medical tourism industry. In fact, it has been ranked the most popular medical tourism destination by many. Apart from the contribution of government and hospitals in improving the health care service in India, what truly gives that edge to India over other medical tourism destinations is the innumerable rejuvenation options it offers and the easiness of stay in India. India is the birth place of Yoga, which is one of the most popular forms of exercise and rejuvenation today. There are almost an infinite number of Spa and rejuvenation centers in India that could uplift the mood and enhance health
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of medical tourists. India is a tourist’s paradise and when in India for medical treatment, tourism comes as a co-benefit of medical tourism. Unlike other exotic destinations in the world, it is surprisingly easy to commute, stay and converse in India. People in India are extremely warm and have a sound command over English. All these factors make India the sought after destinations for medical tourism and India is now equipped to cater to the fast growing demand for health care in India. A new report, "Booming Medical Tourism in India”, provides an insight into the Indian medical tourism market. It evaluates the past, present and future scenario of the Indian medical tourism market and discusses the key factors that are making India a favorable medical tourism destination. Both statistics and trends regarding market size, tourist arrivals, infrastructure, accreditations, drivers and restraints have been thoroughly discussed in the report.

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The competitive cost of medical treatment in India has been the main catalyst for the growth of medical tourism in the country. The costs of comparable treatment in India are on average one eighth to one fifth of those in the West. For instance, a cardiac procedure costs anywhere between US$ 40,000 - 60,000 in the United States, US$ 30,000 in Singapore, US$ 12,000 - 15,000 in Thailand and only US$ 3,000 - 6,000 in India. Likewise, the associated costs of surgery are also low. India also has the potential to emerge as a hub for preventive health screening in view of the availability of low-cost diagnostic tests. At a private clinic in London a health check-up for men that includes blood tests, electro-cardiogram tests, chest X-Rays, lung tests and abdominal ultrasound costs around £350. In comparison, a comparable check-up at a clinic operated by Delhi-based healthcare company Max Healthcare costs US$ 84. A Magnetic Resonance Imaging (MRI) scan costs US$ 60 at Escorts Hospital in Delhi, compared with roughly US$ 700 in New York. A study done by the India Brand Equity Foundation (IBEF) in 2004 showed that India is more cost-competitive as compared to other leading medical tourism destination like Thailand. Thailand has a cost advantage over India in only two categories: plastic surgery and breast augmentation. India is cheaper than Thailand across a whole range of other—and more serious — surgery categories as the following chart indicates. Surgery Bone Marrow Transplant Liver Transplant Open Heart Surgery (CABG) Hip Replacement Knee Surgery Hysterectomy Gall Bladder removal * cost in US$ Thailand US$ 62500 US$ 75000 US$ 14250 India US$ 30000 US$ 40000 US$ 4400

The health US$ 6900 US$ 4500 services US$ 7000 US$ 4500 in India US$ 2012 US$ 511 have the US$ 1755 US$ 555 additional advantage of providing a good mix of allopathic and alternative systems of medicine. For instance, while New Delhi has emerged as a prime destination for cardiac care;
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Chennai has established a niche for quality eye care; Kerala and Karnataka have emerged as hubs for state-of-the-art ayurvedic healing. The scope for profit in this sector has encouraged several large corporations, such as pharmaceuticals and industrial companies, and several non-resident Indians (NRIs) to invest money in setting up super-specialty hospitals such as Apollo, Medinova, CDR, Mediciti in Hyderabad; Hindujas and Wockhardt in Mumbai; Max, Escorts, Apollo in Delhi etc.8 These facilities now dominate the upper end of the private sector and cater predominantly to medical tourists and affluent sections of the society. These establishments have created a niche job market for health professionals predominantly trained in public sector institutes. Even the Government of India has responded promptly to tap the potential of this sector. In its effort to capitalize on this opportunity the Government has untaken measures to promote India as a “global health destination”. The National Health Policy 2002 strongly encourages medical facilities to provide services to users from overseas. It states that “providers of such services to patients from overseas will be encouraged by extending to their foreign exchange, all fiscal incentives, including the status of “deemed exports”, which are available to other exporters of goods and services”. The Indian Ministry of Tourism has started a new category of visas for the medical tourists. These visas called the “M” or medical-visas are valid for one year but can be extended up to three years and are issued for a patient along with a companion. Efforts have also been undertaken to improve the airport infrastructure to ensure smooth arrival and departure of the health tourists. A brochure of the ministry predicts a “phenomenal expansion” of the Indian health-care industry in the coming years. These factors have favored the recent spurt of growth of medical tourism in India. Official figures indicate that medical tourists from 55 different countries come to India for treatment. While most of these patients are from developed countries, India is also seeing a surge of patients from countries in Africa and South and West Asia that lack adequate healthcare infrastructure. Among others, foreign health travelers to India comprise of a large number of nonresident Indians (NRIs). If the present trend continues trade in health and healthservices will become one of the biggest sectors in India. However, there are several challenges that could impede the growth of medical tourism in India, more importantly the growth of this sector poses a threat to the already crippled
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public health system in India.

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Major players offering Medical Tourism packages

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Indian corporate hospitals excel in cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. The various specialties covered are Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Pediatrics, Pediatric Surgery, Pediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery The various facilities in India include full body pathology, comprehensive physical and gynecological examinations, dental checkup, eye checkup, diet consultation, audiometry, spirometry, stress & lifestyle management, pap smear, digital Chest X-ray, 12 lead ECG, 2D echo colour doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, carotid colour doppler, spiral CT scan and high strength MRI. Each test is carried out by professional M.D. physicians, and is comprehensive yet pain-free. Industry Players:• Thomas Cook India Ltd.

Company Information:Thomas Cook (India) Ltd. is the largest integrated Travel and Travel related Financial Services Company in the country offering a broad spectrum of services that include Foreign Exchange, Corporate Travel, Leisure Travel, and Insurance. The Company launched its Indian operations in 1881 and is celebrating its 127 years of world-class service in India. Thomas Cook (India) operates in the following areas of business, namely: Leisure Travel, Corporate Travel Management, MICE, Foreign Exchange, SWIFT Network, Travel Insurance, Credit Cards, Pre-Paid Cards, Life Insurance and E-Business.
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Post March 31st 2008, Thomas Cook (India) Limited (TCIL) is a part of Thomas Cook Group plc UK (TCG). On March 7th 2008, TCG announced its decision to acquire TCIL from Dubai Investment Group. Thomas Cook Group plc is one of the largest travel groups in the world with a market capitalization of approximately US$6 Billion. In June 2006, Thomas Cook (India) acquired LKP Forex Limited and Travel Corporation (India) Pvt. Ltd. (TCI). TCIL presently operates in over 72 cities across over 180 locations. The company has overseas operations in Sri Lanka which is a branch of TCIL and Mauritius which is a subsidiary of Thomas Cook (India). The Company employs over 2,200 resources and is listed on both the Bombay Stock Exchange as well as the National Stock Exchange. Thomas Cook (India), over the years has received several prestigious awards such as the Golden Peacock Award for excellence in Corporate Governance and the Pacific Asia Travel Association (PATA) Golden Award for Best Travel. Recently, the Company won the Best Tour Operator at the CNBC Awaaz Travel Awards 2008 and was also accredited the P1 rating which is the highest financial rating given by Crisil. • Founded in 2007 • Headquarters in Peterborough, England, UK • Key people are Thomas Middlehoff (Chairman), Michael Beckett (Deputy Chairman), Manny Fontenla-Novoa (CEO) • IT is a travel industry • Its products are Package Holidays • Employees are 31000

SOTC - India's Leading Tour operator
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SOTC is Kuoni India's key outbound travel brand. SOTC, India’s largest outbound tour operator was acquired by Kuoni Travels - World's leading premium Tour Operator in the year 1996 and is a leader in all segments, namely Escorted Tours, Free Individual Travel, Special Interest Tours and Domestic Holidays amongst others. Till date, SOTC has escorted over 4 lakh passengers across the globe to various destinations including Europe, USA, Australia, New Zealand, Far East, Africa and many more. They have served travelers for years and won their smiles and hearts. SOTC’s vast array of holiday services is taking holidaying to an entirely new level. SOTC has been voted "Best Outbound Tour Operator" five times in a row by the Galileo Express Travel & Tourism Awards Committee. The company has not only fully utilized the existing market potential but has also created new markets through innovative packages namely ‘BhramanMandal’ brand which is dedicated for the Marathi speaking population and 'Gurjar Vishwadarshan' brand that is dedicated for the Gujarati speaking population. SOTC Corporate (MICE) tours offer the following services to customers: • • • • • • • • • • • • • Research and development of complete program Identification and reservation of location Venue and accommodation selection Planning, organisation and equipping of location area Contracting and negotiation of services Organisation of pre and post tour programs, spouse programs, social programs and arrangements for accompanying guests Specialized exclusive theme dinners Audiovisual recording of the event Shows and special entertainments Special evening venues Transportation - meet and greet services during all arrivals Security Visa application services
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SOTC Trade Fair Tours:SOTC Trade Fair Tours is a division that caters exclusively to the needs and requirements of the keen businessman visiting or exhibiting in International trade fairs. Increase in the number of Indian participants & visitors to various International exhibitions to compete at a global level confirm huge potential for Group Outbound Travel. In the past few years SOTC Trade Fair Tours has successfully organised delegations to various International trade fairs, which has helped in creating awareness and earning a reputation in the market. The efforts and strength in offering the best quality services have been recognized by the 'Indo German Chamber of Commerce', Industry Associations and International Exhibition Organizers, etc by appointing SOTC Trade Fair Tours as their exclusive official agent in India. SOTC Trade Fair Tours has given a new dimension to the trade fair visitors by providing value added services such as confirmed accommodation during the fair period, Indian meals, option to pay in easy monthly installments, factory visits etc - all this and more at extremely attractive and competitive prices.

Major Hospitals:-

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All medical investigations are conducted on the latest, technologically advanced diagnostic equipment. Stringent quality assurance exercises ensure reliable and high quality test results The chief cities attracting foreign patients to India are Mumbai, Bangalore, Hyderabad, Kolkata and Chennai. Similarly, the speciality hospitals excelling in the medical tourism industry in the country are: * Escorts Heart Institute and Research Centre Limited, New Delhi * All India Institute of Medical Sciences, Delhi * Manipal Heart Foundation, Bangalore * B. M. Birla Heart Research Centre, Kolkata * Breach Candy Hospital, Mumbai * Wockhardt Hospitals * Christian Medical College, Vellore * Asian Heart Institute, Mumbai * PD Hinduja National Hospital and Medical Research Centre, Mumbai * Jaslok Hospital, Mumbai * Apollo Hospital, Delhi * Apollo Cancer Hospital, Chennai

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The health care sector in India has witnessed an enormous growth in infrastructure in the private and voluntary sector. The private sector which was very modest in the early stages, has now become a flourishing industry
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equipped with the most modern state-of the- art technology at its disposal. It is estimated that 75-80% of health care services and investments in India are now provided by the private sector. An added plus had been that India has one of the largest pharmaceutical industries in the world. It is self sufficient in drug production and exports drugs to more than 180 countries. * Bone Marrow Transplant * Brain Surgery * Cancer Procedures (Oncology) * Cardiac Care * Cosmetic Surgery * Dialysis and Kidney Transplant * Drug Rehabilitation * Gynaecology & Obstetrics * Health Checkups * Internal/Digestive Procedures * Joint Replacement Surgery * Nuclear Medicine * Neurosurgery & Trauma Surgery * Preventive Health Care * Refractive Surgery * Osteoporosis * Spine Related * Urology * Vascular Surgery * Gall Bladder stones surgery (Laparoscopic Cholecystectomy ) * Hernia surgery (Laparoscopic mesh repair ) * Piles ( Stapled Hemorrhoidectomy ) * Varicose Veins surgery * Endoscopic Thoracic Sympathectomy for Hyperhidrosis * Laparoscopic Appendicectomy * Laparoscopic Adrenalectomy * Laparoscopic Fundoplication for Hiatus Hernia * Laparoscopic Banding of stomach for Morbid Obesity * Laparoscopic splenectomy Other packages include: · Hip-Knee replacement surgeries and other orthopedic surgeries.
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· Bone marrow transplantation surgery. · Heart surgery packages like Cardiac Surgery and Cardiology, Open Heart Surgery, Angiographies and Angioplasties. · Treatments of different skin problems including skin grafting.

The services provided by the host country’s hospital/ organisation are:•

• • • •

Put in touch with a world class Private hospital or Nursing home and the doctor & fix up an appointment with the doctor at the hospital. Receive you at the airport and provide transportation to the hotel and for the rest of the days during your stay here. Provide accommodation in a hotel as per your choice and budget near the Nursing Home or the Private hospital. We can arrange for another place to stay or a rejuvenating sight-seeing tour while your mother recovers after the treatment. In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals. In fact, priority treatment is provided today in Indian hospitals.

STEPS OF SEEKING TREATMENT WITH MEDICAL TOURISM:-

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1. Is the medical ailment suitable for treatment in a country different from yours the patient’s own country. The answer to this question will be based on combined information from your own doctor and the overseas doctor. 2. Ailments that require a one shot treatment like surgery for gall stones, hernia, piles, varicose veins, hysterectomy, adrenalectomy, nephrectomy, thyroidectomy, joint replacement etc are more suitable for medical tourism. 3. The ailment should be such that a follow up should not be necessary and you should not need to visit the country again to ‘tie up loose ends. 4. The patient/ tourist should be otherwise well enough to be able to utilize the tourism part of it. Otherwise you could just go to the hospital directly for treatment. 5. Mostly planned elective surgery for which there may be a long waiting list in your country is best suited for medical tourism. 6. Decide on the country, hospital and doctor who would be treating. This information would be available through the net or from recommendation by another patient. Visit the website of the hospital and doctor is the next step. Writing and asking about their training and experience in the procedure along with the cost implications is vital.

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Who would have thought that in just five years, medical tourism in India will build a remarkable repute as one of the country’s most often visited by foreign patients for affordable plastic surgery and other health care treatments? Not long ago when medical travel was something scary and unrealistic, now American patients are wondering why they haven’t thought of flying to other countries like India where plastic surgery cost is extremely cheap. According to proponents, plastic surgery in India is comparable to much that is available in the U.S. but with great difference in plastic surgery cost. Because of India’s preferable exchange rate with dollar, official figures indicate that among the 55 countries that come to the country for affordable plastic surgery, the biggest growth in business comes from the UK and United States. Frustrated by long waiting list and high plastic surgery cost, patients began considering the option of going abroad for medical care treatments In 2003, James Campbell, a resident from Aberdeenshire, went to Ahmedabad for a double knee replacement at less than half the cost of private treatment in the UK, after organizing the trip and treatment himself because of the tremendous waiting list before he can get his surgery. If patients like James who wants immediate operations, they will usually pay an additional 20-50 percent of the UK cost for prompt surgeries. A single knee replacement in the UK costs about £9,000 but a Madras clinic quotes the operation at £2,150. The number of foreign patients that come for plastic surgery in India increases year after year. To sustain the nation’s operation to offer high quality and affordable plastic surgery, private healthcare companies in India invested about £50 million to acquire state of the art equipments in the past decade. The quality of medical facilities and staff in India is increasingly rated inter Cationally and 75 percent of healthcare services in India are now in private sector and advanced private hospitals have been established in the major cities of the country. Today, plastic surgery in India is one of the respected assets of medical tourism. In fact, a Confederation of Indian Industry report predicts that medical tourism will be worth $1 billion to the economy by 2012. To know more about plastic surgery in India, please visit GoSculptura India and get your free surgeon consultation and a free preview of how you will look like after the surgery. Gosculptura offers medical vacation packages and will take care of all your primary needs in India.

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Majority of the patients come from US, UK and Africa. So hospital should try to capture the number of patients from other than these countries. The majority of the patients are come for the Cardiac, Orthopedic and Gastroenterological diseases, so our hospitals should develop super specialty ward and department to capture more number of patients. Our hospitals should develop alternative therapy ward or department like Ayurveda, Yunani, Spa and Yoga along with the rehabilitation centers. To increase the Advertisement of the Hospitals by using different media. As most of the patients are satisfied with the Treatment and Facilities provided by the hospitals, so hospitals should maintain them. For patients who are dissatisfied with the treatment and facilities, hospitals should try to know the reasons behind the dissatisfaction. Hospital should reduce the Professional Attitude towards the NRIs patients. Increase travel facility for the foreign tourists Visa-on-arrival facility for tourists from selected countries. Improve and modernize airport infrastructure and services. Make more and more advertisement by using different medias to capture more market shares. Create public awareness about economic and social benefits of tourism.

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BIBLIOGRAPHY / WEBLIOGRAPHY –

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"TB Often Misdiagnosed". American Lung Association of Illinois. http://www.lungil.org/il/copd/TBMisdiagnosed.asp. Retrieved on 200703-10. http://www.worldhospitalmonitor.com "Health Tourism 2.0". World Health Tourism Congress. http://www.medtrotter.com/publications/WHTC_2007.pdf. Retrieved on 2007-04-13. SOFIHA - Welcome to SOFIHA Healthcare Tourism International United Kingdom Accreditation Forum Medical Tourism Association "Incision Care", American Academy of Family Physicians, July, 2005, retrieved September 18, 2006 World Alliance for Patient Safety

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