August 200
From the tourism activist network KABANI in India, the author demonstrates the unfair effects of Medical Tourism in India.
Experienced and highly specialised doctors, competent to do the most complicated surgeries, well trained nurses and medical technicians, advanced technologies, luxury specialised hospitals. India has set the stage for the show. These fabulous arrangements are not meant for the country's poor but for the affluent Indian elites and foreign patients. For the latter, even the visa processes have been eased.
The Indian tourism industry is now promoting Medical Tourism as a novel hope for the Indian economy. Five star hospitals are mushrooming around the nation and major investments by big corporate players are expected. The privatisation and 'corporatisation' of health care has created Medical Tourism where people from rich nations travel to third world countries to obtain medical care, experience and enjoy the tourism attractions and use other resources. It is a 'magic lamp' for those countries to attract overseas patients and earn foreign exchange. According to a study by the Confederation of the Indian Industry (CII) and McKinsey, Medical Tourism will bring US$2.2 billion revenues for Indian hospitals by 2021.
India is promoting Medical Tourism in its National Health Policy of 2002 in the following way: "To capitalise 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". This formulation shows the influence of the corporate sector as does the 'Policy Framework for Reforms in Health Care’ which was drafted by the prime minister's Advisory Council on Trade and Industry, headed by big Indian corporate such as Mukesh Ambani and Kumaramangalam Birla.
'First rate medical care at third world prices'
India's corporate hospitals are meeting the requirements of international standards, with cost for a treatment about one-eighth to one-fifth of that in the US or the UK. Therefore, many foreigners are flocking to India to get an affordable and high quality health service. Treatment in India is ‘cost effective’ for patients from rich countries because there is no clear-cut differentiation between Indian and foreign patients in place in India, and medical care costs are exorbitant in their home countries.
Untold facts
Though the boons are loudly proclaimed nothing is mentioned of the banes. Multi-specialty hospitals are getting lump sum of tax exemptions like free or very cheap land, tax holidays, and rebates in customs tariffs, low interest loans from public sector banks etc. acknowledging their key role for revenue generation.
Many of the private hospitals are registered under the Public Trust Act. They are obliged to provide free service of up to 20% of their capacity and are therefore exempted from income tax. (1) However, in the case of Indraprastha Apollo Hospital, New Delhi, one of the premier players in the Medical Tourism arena, it was found that the agreement had been undermined. This hospital was built in 1996 on 15 acres prime land worth an estimated $2.5 million given by the Delhi government free of cost (at a token lease rent of Re 1 per annum). The Delhi government invested $3.4 million in construction of the hospital and contributed $5.22 million as equity capital. Tax and duty waivers on import of equipment etc. were also given. The agreement was that treatment for one-third of the beds would be made available free of cost to poor patients. However, only 2% of indoor cases in 1999-2000 in Apollo Hospital were treated free and most of these were relatives of staff, bureaucrats and politicians. However, the government failed to charge the hospital for failed accountability. If the revenue of such hospitals does not revert and seep into the local population, the revenue boom may turn out to be a myth.
Local people's access to Health Care
Due to the Medical Tourism boom, private hospitals expand and demand more human resources. More and more qualified medical professionals from the public sector and small towns or hospitals are attracted to the metropolitan health centers. Even now, most of the professionals in the private institutes have migrated from government institutions and will remain available only for the foreign tourists and Indian elites. (2) Seventy per cent of the rural population does not have access to proper health care and many choose to not seek any treatment at all as the cost for private practitioners are far beyond their financial possibilities. On the other side, however, the Indian Ministry of Health is accrediting hospitals and recommending prices for their services to guarantee service quality for the Medical Tourism.
For Medical Tourism, only large specialised hospitals run by corporate bodies are promoted to enhance their opportunities beyond the limited domestic ‘market’. Indian private health care costs are likely to hike up as the number of medical tourists increases. Even before the Medical Tourism boom in India, health care was becoming increasingly expensive. In 1987, the cost of a single treatment in the public health sector in Kerala was 16.6 Indian Rupees, but rose to 830.7 Indian Rupees in 2004. (3) With growing attention given to Medical Tourism, quality health care will probably become unaffordable for the common person.
Emigration of Indian medical professionals to other countries is common. Due to Medical Tourism, Indian institutions may be capable of providing attractive salaries which will attract back the drained brains (reverse migration). But the new manifestation in the form of Medical Tourism is just brain drain plus. This requires the skilled person to stay back within the country, get wages marginally higher, use infrastructure and other resources from own country and contribute the whole energy to serve the foreigners. In addition, the poor Indian taxpayers have to finance the training of these professionals since the latter acquire their expertise from government institutions. This provides much higher surplus to the developed country economy.
India as a dump yard
Another serious problem is that corporate hospitals just dump their medical waste in areas where 'ignorant' citizens live as no proper medical waste management system is in place. The local people, however, have no information at all about the threats they are exposed to living close to medical waste dumps. In India, a bed in a hospital generates on average 1 kg waste per day, out of which 10-15% is infectious, 5% hazardous and the rest general waste. To put that in perspective, a big urban corporate hospital generates two million tons of waste each year. (4) As in many developing countries, waste is not separated: from reception-area trash to surgery room waste - all is burnt in incinerators or dumped into rivers or the sea. These external costs are not included at all in the overall running costs, so the businesses are running very cost efficiently!!!
No pain but gain!
This story peaks in a 'no pain but gain' deal: renting a cheap womb in India to make one's dream of one’s own child come true. A much cheaper solution than a infertility treatment in the 'developed' world. There is not much attention on this issue but at least the Tribune Newspaper reported that in Britain, campaigners have questioned the ethics of such a practice. (5) Also, the trade in organs is a serious problem. 96% of people surveyed had sold their organs (mostly kidneys) for an average of US$1,070, and paid off their debts with that money. (6) The majority of those organs are not used in India though where a long waiting list for organ transplantation exists. (7) Despite the 1994 Human Organs Transplant Act which criminalises organ sales (8), due to inefficient control, corruption and better prices paid abroad, illegal trafficking of organs is common. The situation might get even worse with increasing Medical Tourism.
Western countries are increasingly concerned about the quality, expertise, and health standards provided (to their residents) in developing countries. Their governments are thus likely to implement internationally accredited quality systems for hospitals. This, however, will lead to even higher treatment cost.
Medical Tourism is demanding more subsidies and incentives from the government with the argument that it earns high revenues and foreign currencies. But subsidising the corporate sector will reduce even more the already limited health service resources for the poor. How could a country like India dare to promote Medical Tourism when the basic healthcare needs of the majority of its citizens are not even met? Why should the poor Indian taxpayer pay the price for treatments of Medical Tourists? Need of the hour is India should focus on assuring basic healthcare as a right to its citizens.
Note: 14 lakh = 1,400,000 (1.4 million); 1.6 lakh = 160,000; 12.4 lakhs = 1,240,000 (1.24 million)
(1) http://www.expresshealthcaremgmt.com/20030930/oped01.shtml
(2) Health System in India: Crisis & Alternatives :October 2006, National Coordination Committee, Jan Swasthya Abhiyan
(3) Prof TP kunjikkannan et al, ‘Kerala Padanam’-keralam engine jeevikkunnu? Keralam engine chinthikkunnu? Kerala Sastra sahitya parishat, sept 2006,pp107
(4) Ratna Singh, Alarming morass of medical waste, http://www.toxicslink.org/art-view.php? id=8
(5) The Tribune-Saturday, April8, 2006
(6) http://www.medscape.com/viewarticle/538831
(7) Frontline, Volume 19 - Issue 10, May 11-24, 2002
(8) Further details of the law can be obtained from http://www.indialawinfo.com/bareacts/transplant.html#_Toc498337703
About the writer: Nikhila M. Vijay is an active member of KABANI, a collective from India working on tourism.
The above is an edited version of an article which first appeared in Contours, Vol.17 #2 June-July 2007, a publication of the Ecumenical Coalition on Tourism (ECOT). It was reproduced with permission by the Third World Network
