The Advent and Growth of Medical Tourism in India with Reference to Neurosurgery
The practice of traveling across international borders to seek medical services is generally referred to as “medical tourism.” Though the term “medical tourism” has been used synonymously with “health care tourism,” the two need to be distinguished.1 Health care or wellness tourism includes rejuvenation and alternative therapies like yoga, Ayurveda, etc., in which a country like India has a long tradition of niche market share. Increasingly, the term “medical value travel” (MVT) is being used as it more accurately reflects a patient’s health care seeking behavior; in most part based on the economic impact on the host nation.2 Countries actively promoting medical tourism in Asia include India, Malaysia, Singapore, South Korea, and Thailand.
India has become a popular destination for medical tourism for a variety of reasons. The Medical Tourism Market Report: 2015 stated that India was “one of the lowest cost and highest quality of all medical tourism destinations, as it offers wide variety of procedures at about one-tenth the cost of similar procedures in the United States.”3 In 2016, India’s medical tourism sector was estimated to be worth $8 billion.4 This is expected to rise at a compound annual growth rate (CAGR) of 15–25 percent until 2020.2
Increasing numbers of foreign tourists are visiting India2,5 over the years. (Figures 1, 2). The number of medical visas issued by India in 2013 was 56,129, in 2014 it was 75,671, and in 2015 it increased to 134,344.6 However, the fact remains that a significant percentage of patients who seek treatment are on a general tourist visa to circumvent the paperwork involved in getting medical visas. The majority of patients come from three world regions: The first major block is Asia, and includes Bangladesh (68,034 patients in 2015), Afghanistan (19,644), Bhutan, Sri Lanka, and Nepal, which, as part of the South Asian Association for Regional Cooperation (SAARC) countries, find that India is a natural destination—being in the immediate neighborhood. The second major block of patients come from the Middle East, and include Iran (5,656), Iraq, the central Asian region, and other Middle East regions, including Oman (4,728). The third major block is Africa, with Nigeria (5,765), Kenya, and Tanzania being the major contributors. Other countries with significant medical tourists visiting India included Maldives, Russia, and virtually every major African country other than South Africa.
Figure 1. Foreign tourist inflow to India 1999–2015 (Source: Ministry of Tourism website)
The vast majority of medical patients are being treated at corporate hospitals which are concentrated in metro cities such as New Delhi, Mumbai, Chennai, Hyderabad, Kolkata, Bengaluru, Pune, and Kochi. The largest chains of corporate hospitals in India in terms of bed strength are the Apollo Group and Fortis Group, with a bed strength of approximately 10,000 beds each.7 The approximate number of beds in various private hospitals treating these patients is about 50,000 to 60,000.
Figure 2. Percentage of medical tourists from various countries in 2014.
(Source: FICCI knowledge paper)
Factors Leading to Medical Tourism in India
India has become a popular destination for medical tourism for a variety of reasons1,2,9,10 which include:
- Competent and skilled doctors, nurses, and allied medical staff.
- Well-equipped hospitals with national and international accreditation.
- Availability of latest technology.
- Significantly lower cost of medical treatment compared to developed countries.
- English is widely spoken by healthcare professionals and translators are readily available for other languages.
- No waiting period for patients to undergo treatment/procedure.
- General perception of India as being friendly and sensitive to these patients.
- Medical insurance companies in developed countries are increasingly recognizing India’s potential as a global health care destination.
Neurosurgery in India
The first neurosurgical department in India was set up the Christian Medical College, Vellore, Tamil Nadu in 1949.11 Subsequently, the growth of neurosurgery in India has been phenomenal. Currently there are 75 centers with MCh neurosurgery training programs, with 277 seats per year,12 apart from one-tenth of trainees in the DNB Neurosurgery program.13 The current number of neurosurgeons in India serving a population of 1.2 billion people is approximately 1,800, with the number rising annually.14
A large number of neurosurgeons have done fellowships in the US, UK, Europe, and Australia after completing their basic neurosurgical training in India. They have subsequently returned to India and brought back valuable subspecialty expertise. The Neurological Society of India (NSI) was founded in 1951 and acts as the parent society. It has affiliated subspecialty societies for cerebrovascular neurosurgery, skull base neurosurgery, stereotactic and functional neurosurgery, pediatric neurosurgery, and neurotrauma.15 These societies have annual conferences and training courses for residents and young neurosurgeons.
Accredited Neurosurgical Centers in India
Currently there are 30 hospitals in India which are accredited by the Joint Commission International (JCI), which is the international arm of the Joint Commision Accreditation for Hospital Organizations (JCAHO).16 Of these, 24 hospitals are providing neurosurgical care. This assures that the quality and standard of care provided are up to international standards, and are focused on patient safety. The National Accreditation Board for Hospitals and Healthcare providers (NABH) is an institutional member of the International Society for Quality in Health Care (ISQUA). ISQUA is an international body which grants approval to accreditation bodies in the area of health care as mark of equivalence of accreditation program of member countries. Currently there are 425 hospitals in India which are NABH accredited.17
Hospitals providing neurosurgical care are equipped with the latest generation of CT and MRI scan machines, angiography suites, and PET scans. Major neurosurgical operating centers are equipped with the latest operating microscopes, high-speed drills for craniotomies, as well as navigation equipment that enables standard neurosurgical procedures to be performed routinely. A few centers in the country also have intra-operative CT/MRI/ ultrasound and the Mazor Robotic spinal guidance system. There are several centers with comprehensive neurosurgical facilities including stereotactic radiosurgery (Gamma Knife, Novalis, Cyberknife, TrueBeam, etc.), epilepsy surgery, deep brain stimulation, and other functional procedures, endoscopic brain and spine surgery, endovascular neurosurgery, minimally invasive spine surgery, and robotic surgery.
Costs of Standard Neurosurgical Procedures in India
Comparative costs of standard therapies across all specialities is shown in Table 1.2 The cost of a diagnostic brain CT scan in India ranges from $40-50; a contrast MRI costs $100-150, and a whole body PET-CT scan costs $300- 400. The cost of a single level lumbar fusion could range from $6,000-10,000 depending upon the type of implant used and equipment used such as navigation, robotic assisted, etc. The cost of stereotactic radiosurgery would be $4,000-5,000; bilateral deep brain stimulation (DBS) could cost $15,000-23,000 (depending upon the type of IPG); a typical VP shunt would cost $2,000-3,000 (indigenous versus variable pressure); a typical craniotomy would cost $6,000-8,500 (depending upon the complexity and duration of stay), and a flow diverter intracranial stent would cost $20,000. Scoliosis surgery using internationally recognized implants such as Medtronics and Globus would cost $15,000. (The costs mentioned above are indicative of the approximate treatment costs at the authors’ hospital and could vary at other centers in India.)
Table 1. Comparative costs of common procedures in various countries.
(Source: FICCI knowledge paper)
Initiatives by the Government of India to Promote Medical Tourism
The Government of India is taking steps to make India stand out in the area of medical tourism.2 Four ministries, including Ministry of Health and Family Welfare, Ministry of Tourism, Ministry of Commerce, and Ministry of AYUSH, along with Services Export Promotion Council (SEPC) and NABH, are involved in promoting India as the preferred destination for medical tourism. The government has also set up a National Medical & Wellness Tourism Promotion Board to look into the various issues such as accreditation and marketing, to give the highest assurance to travelers. A dedicated website has been created by the government to present India as the preferred health care destination.5 The SEPC website18 has a detailed listing of accredited hospitals and health care providers with comparative costs for various medical procedures and other allied facilities. The government has also launched an e-visa application website where tourists from 158 countries may apply safely online for a visa (the visa is valid for medical treatment also).
Challenges for the Medical Tourism in India
There is a variable cost structure with wide differences in the infrastructure and neurosurgical expertise across hospitals. There is a large number of hospitals and smaller nursing homes lacking international accreditation. India has pockets of well-developed health care systems, but the country is still developing, and there are problems with roadways, air connectivity, pollution, cleanliness, etc., which are currently being addressed.1,9,10 There is also a lack of a grievance redressal system for medical tourists and there are medicolegal issues which still need to be addressed.10 While large data is available for tourism in general, there is limited data on medical tourism specific to neurosurgery.
1 Sravana Kumar G, Krishan Raj R. Status, Growth and Impact of Medical Tourism in India. Int J Pharm Sci Rev Res. 2015:34:284-291.
2 Medical Value Travel in India: Enhancing Medical Value in India. FICCI (Federation of Indian Chambers of Commerce and Industry) knowledge paper Oct 2016. Joint Initiative of FICCI, SEPC, imshealth and Department of Commerce, Ministry of Commerce and Industry (Govt of India)
3 Medical Tourism Market Report 2015
4 Economic Times : http://economictimes.indiatimes. com/industry/healthcare/biotech/hyderabad-to-hostinternational- medical-tourism-congress-in-september/ articleshow/53831661.cms
6 Economic times: http://economictimes.indiatimes.com/ nri/visa-and-immigration/Medical-tourism-sees-healthygrowth- 13-lakh-visas-in-2015/articleshow/53428421. cms
7 http://www.india-opportunities.es/archivos/ publicaciones/Healthcare-January-2016.pdf
9 Sharma A. Medical tourism: emerging challenges and future prospects. International Journal of Business and Management Invention 2013:2;21-29.
10 Benur S. Medical Tourism: Can it be A New Supernova of Indian Economy. Asian Journal of Management Sciences 2014:02;10-17.
11 Rajshekhar V. History of neurosurgery at Christian Medical College, Vellore: A pioneer’s tale. Neurol India. 2016 Mar-Apr;64(2):297-310. doi: 10.4103/0028- 3886.177625. 12 MCI website - http://www.mciindia.org/InformationDesk/ CollegesCoursesSearch.aspx
13 National Board of Examination website - http://www.natboard.edu.in/
14 Ganapathy K. Neurosurgery in India: An Overview. World Neurosurgery. DOI: http://dx.doi.org/10.1016/j. wneu.2013.02.071
15 NSI website - http://www.neurosocietyindia.com/
16 JCI website - http://www.jointcommissioninternational. org/about-jci/jci-accredited-organizations/?c=India
17 NABH website - http://nabh.co/frmViewAccreditedHosp. aspx
18 SEPC website - http://www.servicesepc.org/services/healthcare-service/