Concept Note on Preparation of Standard Operating Procedure for Medical Tourism in India
Dr. Jugal Kishore, Professor & Head and Dr. Sanjeet Panesar, Senior Resident
Department of Community Medicine, Vardhman Mahavir Medical College, & Safdarjung hospital, New Delhi; Email: firstname.lastname@example.org
Medical tourism focuses on treatment of acute illnesses, elective surgeries like in cardiology, oncology, orthopaedics, etc. with an objective to promote India as a health destination for persons across the globe so as to gainfully utilize the healthcare expertise and infrastructure available in the country in view of increasing longevity of life. Health tourism also focuses on wellness, rejuvenation, preventive health, image health combined with traditional medicine like Ayurveda, Yoga, etc. In simple term medical tourism is tourism for health reasons. This tourism, widely also known as medical travel, health tourism or global healthcare tourism, covers all types of medical disease and health conditions, and provides healthcare at an affordable cost.
Indian medical tourism is growing very fast according to CII-McKinsey report 2000. With state of the art medical facilities, with ability to speak English, India has some of the world’s best health professionals and latest medical equipment with excellent technology and infrastructure that meet the stringent standards of the US Food and Drug Administration. However, the first choice is for medical tourism is Thailand. Citizens of countries like Great Britain and Canada, who have national health care schemes, often undertake overseas travel to cut down on extra waiting time. (1) Similarly, others might head abroad to get a cosmetic surgery done since it is not covered by most insurance providers. India is one of the cheapest countries to provide quality healthcare. Cost of the many procedures is just 6% to 21% of the US expenditure. India deals with a high proportion of major surgery tourists than the other countries, which has given rise to specialist corporate hospitals across India. These hospitals are far out of the reach of most Indians and cater specifically to foreign tourists for various specialities – for example some centres will focus strongly on heart surgery while others will deal with joint replacements. These specialist hospitals are very new with top rate medical teams, high volume and experience in their specialty and the best equipment available. High volume of heart surgeries does not translate into high volumes overall, however, and these hospitals rely heavily on the internet, to recruit prospective patients. These facilities also offer procedures that are rare or unavailable in the United States, such as hip polishing or resurfacing, which is a popular surgery for medical tourists.
Tourism in India is impressive and most of the patients are satisfied but at the same time can be quite uncomfortable. Though excellent hotels and western restaurants are available, they are extremely expensive. Most of the cities of the country are having mixed rural slum and urban population with poor sanitation condition therefore travellers are very likely to suffer from diarrhoea and intestinal infections. Law and order issues are also emerged out from free flow of medical tourists in India. Besides the tourists India receives every year a lot of foreign students for international study and research, who if fall ill, are catered to by the Indian system of healthcare. Though the government and private hospitals provide treatment to these foreign students in special circumstances (2), many ethical, medico-legal and financial issues arise out of this which may affect medical tourism as well as well international diplomatic relations among the countries. Therefore an urgent need is to develop Standard Operating Protocol for treatment of Foreigners under medical tourism.
Scope of Health Tourism and present status in India
The Indian systems of medicines, i.e. Ayurveda, Yoga, Panchakarma, Rejuvenation Therapy, etc. are among the most ancient systems of medical treatment, of the world. Southern States of India, especially Kerala, has developed health tourism as one of the products for the promotion of tourism in Kerala. Health Tourism has also been promoted as one of the Unique Selling Points of the State. Most of the hotels/resorts are coming up with the Ayurveda Centres as an integral part. Most of the foreign tourists are now coming to India only for Ayurveda. The leading tour operators have included Ayurveda in their brochures. (3)
India’s medical tourism sector is expected to experience an annual growth rate of 30%, making it a $2 billion industry in 2015. (4) Most of the foreign patients are satisfied with the treatment but more need to be done (5). As medical treatment costs in the developed world rise - United States leading the way - more and more foreigners find the prospect of international travel for medical care increasingly appealing. According to an estimated 150,000 of these patients are travelling to India for low-priced healthcare procedures every year. Cosmetic surgery, Bariatric surgery, Knee cap Replacements, Liver transplantation and cancer treatments are some of the most sought out medical tourism procedures opted by foreigners. Some of the leading hospitals for medical tourism are corporate promoting Health Tourism worldwide.
The growth of Medical and Health Tourism in India is higher because of advantages such as:
1. Availability of world-class doctors and hospitals
2. The cost of the treatment is a fraction of cost in the source markets
3. Very low or no waiting period for various medical processes
4. Increasing popularity of India as a tourist destination in the west
5. Eastern Healthcare Wisdom along with the expertise of Western Medicine.
6. English Speaking health care workers
The Ministry of Tourism has taken several steps to promote India as a Medical and Health Tourism Destination, which are as follows: (3)
1. The Confederation of Indian Industry, on advice by Government, has prepared a guide on select Indian hospitals of the country for health tourism purpose. It has been placed on the Website of the Ministry of Tourism i.e. www.incredibleindia.org for wider publicity.
2. Indian Healthcare Federation, a Non-Governmental organisation affiliated to Medical and health tourism has been specifically promoted at various international platforms such as World Travel Mart, London, ITP Berlin. Similarly, Website on tourism have been produced by the Ministry of Tourism and have been widely circulated for publicity in target markets.
3. A new category of 'Medical Visa' has been introduced, which can be given for specific purpose to foreign tourist coming to India for medical treatment. The government of India issues medical visa to every medical tourist and this visa can also be extended for over a year. This extended time of visa enable the patients to visit three times in a year and these patients can also be accompanied by a relative or friend at the time of medical tour to India.
4. Guidelines for accreditation of Ayurvedic and Panchkarma Centres have been circulated to all State Governments for implementation. These have been placed on the website of Ministry of Tourism i.e. www.incredibleindia.org for wider publicity.
5. Yoga/Ayurveda/Wellness has been promoted over the last two years in the print, electronic, internet and outdoor medium under the Ministry of Tourism's "Incredible India Campaign''.
6. Brochures & CDs on Body, Mind and Soul covering the traditional system of medicine have been produced and circulated extensively by the Ministry of Tourism.
7. Market Development Assistance (MDA) Scheme in the Sector: The Ministry of Tourism has included the promotion of Medical Tourism as new initiatives. The Marketing Development Assistance Scheme (MDA), administered by the Ministry of Tourism, Government of India, provides financial support to approved tourism service providers
Existing guidelines in India:
Guidelines are given to traveller who is visiting India for medical tourism to avoid any kind of uncertainties or problems–
• To ensure that the hospital in India to be visited is licensed or not. The hospital must be recognized by a commission, any international healthcare auditing agency or by a Joint Commission International.
• To check the cost and quality of patient care.
• To get all possible details about the doctors before selecting them that includes their credentials, achievements and qualification. It is advisable to search about the hospital credentials on the internet.
• It is crucial to know about treatment procedure well in order to have realistic expectations from the surgery. Patients should also be clear about post-operative care, recovery period and physical therapy.
• Make sure to meet the treating doctor in person before undergoing any procedure. Personal examination such as diagnostic tests of a patient is first performed by the majority of hospitals to assess the possibility of conducting procedure.
• Make sure to carry all the essential documents along with their copies by the patient and store the originals in a safe place.
• To carry all the health records and medical reports that are relevant to the medical procedure or surgery such as prescriptions, X-rays, health histories, immunization records, MRI’s and photographs.
• Passport and Visa required along with debit cards, credit cards and travellers check. Also bring one or two major debit and credit cards, and some local currency.
• Make sure to carry your driver’s license that remains valid till the time you are travelling.(3)
The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider, who is commonly referred to as a "facilitator". The facilitator 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, such as x-rays or diagnostic testing results. Certified physicians or consultants may advise on the medical treatment or recommend an initial consultation with a specialist. The approximate cost of treatment, the choice of doctor and hospital, expected duration of stay, and logistical information, such as accommodation, ground transportation, and flights are discussed as well. A patient may be asked to pay an upfront deposit for treatment. For those destinations which require a visa, the patient will be given recommendation letters for a medical visa for the relevant embassy. The patient travels to the destination country, where the medical tourism provider may assign a case executive, who takes care of on the ground experience, including translation, accommodation, and arranging aftercare. In the cases where patients self-pay for medical treatment, a final treatment bill will be presented upon completion of treatment. If the patient underwent surgery, there may be additional post-operative checks to discharge the patient and deem him or her "fit for flight" for the return home trip.
International Health Accreditation:
International healthcare accreditation is the process of certifying a level of quality for healthcare providers and programs across multiple countries. These organisations such as Canadian Council on Health Services Accreditation, Joint Commission International, United Kingdom Accreditation Forum, etc., certify a wide range of healthcare programs such as hospitals, primary care centers, medical transport, and ambulatory care services. (7,8) Joint Commission International is similar to the Joint Commission in the United States. Both are US-style independent private sector not-for-profit organizations that develop nationally and internationally recognized procedures and standards to help improve patient care and safety. They work with hospitals to help them meet Joint Commission standards for patient care.(9) 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.(10)
Medical tourism carries some risks also to central and local government:
1. Some countries, such as South Africa, or Asian countries 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, enteric fever, amoebic dysentery), which could weaken progress and expose the patient to mosquito-transmitted diseases, influenza, tuberculosis, etc. These diseases may not be picked up by doctors in their native countries because such diseases are perceived to be "rare" in the West. (11)
2. 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. Also, travelling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility associated with window seats can predispose one towards developing deep venous thrombosis and potential risk factor for pulmonary embolism. (12)
3. Other vacation activities can be problematic as well, cosmetic issues for example, scars may become darker and more noticeable if they sunburn while healing. (13)
4. Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dis-satisfied patients. (14)
5. Differences in healthcare provider standards around the world have been recognised by the WHO, 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. (15)
6. If there are complications, the patient may need to stay in the foreign country for longer than planned or if they have returned home, will not have easy access for follow up care. (16)
1. Receiving medical care abroad may subject medical tourists to unfamiliar legal issues. (17)
2. The limited nature of litigation in various 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.
3. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits.
4. 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. (18)
5. Issues can also arise for patients who seek out services that are illegal in their home country. In this case, some countries have the jurisdiction to prosecute their citizen once they have returned home, or in extreme cases extraterritorially arrest and prosecute. (19)
6. There are no clear policies addressing the disputes arising from treatment, complications and adverse reactions and death. No policies addressing the insurance and offshore agencies involved in medi-claims or health insurances. There are no robust and clear policies addressing on the medico-legal, post mortem dissections.
1. There are some ethical issues involved in medical tourism. (17). For example, the illegal purchase of organs and tissues for transplantation had been methodically documented and studied in countries such as India. (20,21) The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation”. (22)
2. Medical tourism may raise broader ethical issues for the countries in which it is promoted. For example, in India, some argue that a "policy for promotion of medical tourism to foreign patients and national health missions for general public will lead to a deepening of the inequities" already embedded in the health care system. (23)
3. Medical tourism centered on new technologies, such as stem cell treatments, is often criticised on grounds of fraud, lack of scientific rationale and patient safety. The affordability by the foreign Nationals of the facilities such as Organ Transplantation deprives the nationals of the host country of the organ transplantation.
However, when pioneering advanced technologies, such as providing 'unproven' therapies to patients outside of regular clinical trials, it is often challenging to differentiate between acceptable medical innovation and unacceptable patient exploitation. (24,25)
1. Policy development:
a. There is a need of National medical tourism policy to promote and handle medical tourists.
b. Clear cut guidelines should be prepared for infrastructure development, transport, visa, price banding, quality assurance, accreditation, training, legal and personal safety of medical tourist, health professionals and hospitals, at the same time maintaining social cost for the benefit of the general public.
c. Guidelines for infection control for biomedical waste management, patients’ satisfaction and safety should be made mandatory.
2. Coordination with concerned ministries and other departments
Multiple agencies in the form of different ministries or stakeholders are involved and a clear and transparent dealing with a medical tourist involves multiple stakeholders; A Committee needs to be formed which will include representatives from all stakeholders such as MOFHW, Ministry of Tourism, Ministry of Home Affairs, Ministry of External Affairs, Ministry of Commerce, Medical Council of India, National Accreditation Body for Hospitals, Indian Medical Association and participants from various Corporate Hospitals and Govt. Hospitals. This committee will provide a platform for regular meeting to supervise, strengthen, direct and promote Medical Tourism and address issues, develop guidelines etc. to provide solution to various short term as well as long term issues having indirect or direct implication to Medical Tourism.
3. Resource development:
a. List of hospitals which have been empanelled for medical tourism (procedures emergency and elective, Accreditation, ISO certification etc.)
b. Water and sanitation including personal hygiene of the employees are the major concerned for medical tourists (5).
c. Health Professionals should be trained in special issues such as to understand the cultural values, expectation and needs of medical tourists. All members of the team dealing with medical or health tourism should be trained in soft skills.
d. Upgrading basic services and information system: basic services, air connectivity, road link, internet connectivity, site seeing, round the clock interpreter, etc are important issues need to be tackled.
4. A detailed catalogue development having details regarding:
· Processes for engagement with residents of various countries:
· Treating doctors, referral and communication with various health care facilities or their representatives.
· Types of illnesses: list of diseases/illnesses to be outlined by various hospitals
4. Development of a uniform and acceptable standard performa for coordination: agreement/MOU/communication to Govt. agencies, having the details of the patient seeking healthcare facility such as,
· Personal details
· Illness details and type of procedure/treatment recommended
· Tentative period (and dates of visit or revisit)
· Hospital and department details
· Physician/surgeon (with team) responsible, if finalised
· Procedural details, discharge summary (with side-effects and complications, if any)
· Follow-up, responsible doctor in local country (his communication) for follow up
· Passport or study visa or work permit
5. Besides this protocol need to be developed for addressing aspects namely:
⁃ Public health: Public health risk associated, international health regulation (IHR) issues, epidemiological investigation, etc.
6. Format needed to be developed for a uniform and real time Record keeping, reporting mechanism, data compilation which will help in coordination between various stakeholders and maintaining transparency.
7. Provision needs to be made to address various legal issues: such as Disputes regarding treatment, complications or death
8. An Advisory will be sent to the State Health Services with Performa to share Medical Tourism Data collected, if any and this shall be supervised by the MOHFW.
9. International Medical Tourism Conference would be conducted jointly by IMA, MOC, MOHFW, and Ministry of Tourism.
10. At the level of International Airports: A Medical Desk needs to be set-up for the assistance of Passengers on Medical Tourism for faster immigration clearance.
1. Medical India tourism. available at www.incredibleindia.org ministry of tourism, government of India assessed on 28th February 2016.
2. Admission Handbook for patients available at www.sgh.co.sg patient admission accessed on 12th March 2016.
3. WriteReadData/1892s/Medical%20tourism.pdf. Available at www.mohfw.nic.in accessed on 15-03-2016.
4. Indian Medical Tourism to touch Rs 9,500 Crore by 2015. The Economic Times, http://economictimes.indiatimes.com/indian-medical-tourism-to-touch-rs-9500-cr-by-2015-assocham/articleshow/3943611.cms
5. Grewal I, Das JK, Kishore J. Concerns, Expectations and Satisfaction of Medical Tourists Attending Tertiary Care Hospitals in New Delhi, India. JIMSA 2012; 25 (3): 151-154.
6. Swamis to surgeries. Medicaltourismmag.com, January 19, 2011.
7. Joint commission International Accreditation and certification web, Joint Commission International, retrieved 19 July 2011.
8. Medical Tourism Magazine, Medical Tourism Association, February 2008.
9. Facts about Joint Commission International. Joint Commission. 2008-12-11. Retrieved 2010-09-15.
10. India: Accreditation a must, International Medical Travel Journal 2015.
11. TB often Misdiagnosed. American Lung Association of Illinois. Archived in March 1, 2007. Retrieved 2007-03-10.
12. New DVT Guidelines: No Evidence to support “Elective class Syndrome”; Oral contraceptives, Sitting in a window seat, advanced age and pregnancy increase DVT risk in long distance travellers . American College of Chest Physicians. 7 February 2012. Retrieved 10 February 2012.
13. Caring for your incision after surgery. FamilyDoctor.org, American Academy of Family Physicians, December, 2010. Retrieved July 23, 2013.
14. Compliments, Comments, Concerns or Complaints. The Pennine Acute Hospitals. Retrieved 2015-01-01.
15. World alliance for patient safety. WHO.int. 2010-05-05. Retrieved 2011-10-29.
16. Ginger Rough (June 7, 2009).Globe trotting to cut down on medical costs. The Arizona Republic. Retrieved 1 January 2013.
17. Medical Tourism: Ethical pitfalls of seeking healthcare overseas. Ahcpub.com. Retrieved 2011-10-29.
18. Medical protection society MPS UK. Medicalprotection.org. Retrieved 2011-10-29.
19. Cohen, Glenn (2012). "Circumvention Tourism". Cornell Law Review 97 (1309).
20. IFTF’s Future now: the dark side of medical tourism. Future.iftf.org. 2006-04-19. Retrieved 2011-10-29.
21. Chopra, A. Organ transplant black market thrives in India. The San Francisco Chronicle (February 9, 2008)
22. Participants in the International Summit on Transplant Tourism and Organ Trafficking convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, 30 April to 2 May 2008. "The Declaration of Istanbul on Organ Trafficking and Transplant Tourism." Kidney International 74, no. 7 (2008): 854-59.
23. Gupta AS. Medical Tourism in India: Winners and Losers. Indian J Med Ethics 2008; 5(1): Jan March.
24. Lindvall O, Hyun I. Medical Innovation versus stem cell tourism. Science. 2009 Jun26;324 (5935):1664-5. Ncbi.nlm.nih.gov. 2011-10-03. Retrieved 2011-10-29.
25. ISSCR Guidelines for the clinical translation of stem cells.2008 Archived June 3, 2009.