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World Health Opportunity

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Resting in his twin-sharing room in Delhi's Max Hospital, Gerald Nnaemeka Nagbo, 42, smiles and poses a counter question: "How much do you know about Nigeria?" I had asked him where exactly his place in Nigeria was. He hails from Abuloma, a small town in South Nigeria, he says. He works in an oil processing unit, and has travelled to India with his younger brother for treatment for spinal cancer, which had been detected early. "In Nigeria, there are no good equipment (in hospitals). We have come to India because we can never get this treatment back home."

Gerald's selection of India with Max as his treatment destination, and his travel to the country has been remarkably easy and quick. A friend who had undergone treatment in India had recommended the country. Gerald had no trouble locating a facilitation agent in Nigeria, who put him in touch with doctors in India, had his reports assessed, processed his papers and visa, and organised his travel to India. Gerald has been in India for just over two weeks now, and expects to be discharged shortly.

That India has emerged as a significant destination for medical treatment and tourism is not a new story. The country offers great value for money in terms of medical treatment for both the visitors from developed countries as well as developing countries. Most of the bigger corporate hospitals in India have state-of-the-art medical facilities and equipment, and highly experienced doctors. More importantly, they offer treatment at between half and one-third the cost of similar treatments in neighbouring medical tourism hotspots such as Singapore and Thailand. And that is why some intrepid patients started flocking to India almost a decade ago in search of treatment and cure.

India has an edge over south-east Asian countries, says Pradeep Thukral, executive director of the Indian Medical Travel Association, an independent body. "Singapore is two to three times more expensive than India, Thailand is 50-80 per cent more expensive, while Malaysia is not a strong player right now," he says.

But as an industry, medical tourism in India has always suffered from official apathy — and it continues to do so. The problem is that it falls between three ministries — all of which look at the business with a degree of suspicion. The tourism ministry in India hasn't really figured out any plan for this niche. The foreign ministry issues visas to medical travellers but wants to have nothing to do with the sector otherwise. And the health ministry has enough domestic issues to sort out without getting into the complexities of attracting medical tourists.

To a large extent, therefore, travellers in search of medical treatment in India came only because they had spent a considerable amount of time researching the destination and its facilities on their own and shown a degree of initiative. In contrast, in countries such as Thailand and Singapore, the governments went out of their way to attract medical travellers after realising its revenue potential.

"Visas are becoming a nuisance; if our basics are not in place, how can we talk of beating Thailand and Singapore, which give visa on arrival?" asks Ashok Maini, president, corporate development at Indraprastha Apollo Hospitals. Maini explains the complexity of the medical visa, given once the patient gets in touch with the hospital and his case reviewed. Another shortcoming is that you cannot re-enter the country 60 days after you exit post operation or cure. "This hinders any post-operative care or reconciliation," he says.

Over the past few years, though, the medical tourism story has changed dramatically in India. Not because the government has figured out the solution. But purely because of private enterprise — with a few corporate hospitals, chemists, freelance agents all working in tandem to build a thriving ecosystem that educates, facilitates and ferries medical tourists from across the world. Last year, this ecosystem was responsible for about 600,000 patients travelling to India and spending Rs 4,500 crore in getting treated here. (The numbers are industry estimates as the government does not have any official statistics on the subject.) Corporate hospitals such as Apollo, Fortis Hospital and Max as well as business associations estimate that the business is growing by 40 per cent year-on-year. In the process, it is not only providing good revenues and profits to hospitals, but also giving rise to employment opportunities for a host of people connected peripherally with the business.

The Globe Trotters
At Delhi's overflowing Fortis Escorts hospital, there is a small office tucked away in the basement. Sunil Kapur, chief sales officer, heads the international marketing business for the Fortis chain (29 hospitals in 11 cities). Armed with a squad of 20 people, Kapur has spent three years at Fortis, travelling to the far ends of Africa and the Middle East, and turned it into a thriving business growing at a scorching pace.

"We started our international business about four years ago on a much smaller scale than what it is today. Sitting here, we were trying to do business development through people who were working either as facilitators or local doctors in other countries," says Kapur. But foreign patients were a mere trickle at that point.

About two years ago, Kapur says, Fortis decided to take the business seriously. A team was recruited and they fanned out to the major cities of the geographies with most potential — Africa and Middle East — to tie up with local doctors, set up facilitation centres, and drum up business. "From a turnover of Rs 9 crore in 2008, we should be closing in at Rs 100 crore this year, which will be 10 per cent of the entire business of Fortis." Kapur is hoping to double this revenue by 2012.

Kapur travels incessantly — over the next three months, he will visit half a dozen countries in Africa and Europe. And he says Africa is the most fertile market for the chain given the decrepit medical facilities in the continent. On his last visit to Africa, he found himself in Lagos. "The hospitals there are run on generators. When I visited, patients were lying in ICUs (on ventilators) without any electricity. The situation is similar in Burundi, Congo, Zambia, Zimbabwe and Ethiopia," he says. On the other hand, while Europe has good medical facilities, the costs are sky-high, and often the waiting lists in many hospitals are very long.

Thailand: The country welcomed 10 million medical tourists for the first eight months of 2010. Major treatments include dental, lasik corrective surgery, cosmetic surgery, holistic and anti-ageing treatments, and medical checkups.

Malaysia: An upcoming destination, this south-east Asian country treated 425,500 international patients in 2009. As per estimates, 689,000 people will travel to Malaysia for treatment by 2012.

Brazil: Well known for cosmetic surgery. Common procedures such as tummy tucks, breast augmentations, facelifts and rhinoplasty, cost as little as $3,000-$6,500.

Singapore: There are vast options in this country — cardiology and cardiac surgery, gastroenterology, general surgery, hepatology, neurology, oncology, ophthalmology, orthopaedics and even stem cell therapy.

The trouble-torn spots of Afghanistan and Iraq are also great places for making a sales pitch. Hari Boolchandani, head of the international patient services at Max (New Delhi) and Kapur's peer in the business, talks about his last visit to Afghanistan three months ago. "Kabul, which houses 40 per cent of the population, doesn't have a single cardiac or advanced neuro centre. Joint replacement is done in one hospital only." In Kabul, much of the hospital infrastructure has been reduced to rubble, and it will take many years to rebuild, which is why any serious patient has to look overseas for
good treatment.

A visit into Boolchandani's office in Delhi provides a good insight into what he considers potential markets. In his office, neatly marked out maps of the Middle East and Africa occupy the wall behind him. Max has seen a 500 per cent growth in medical tourist arrivals over the past three years. "In 2008, we received close to 600-700 international patients, that number touched 4,000-4,500 this year (in-patients only, out patients would be close to 20,000)," adds Boolchandani. Currently, he says, the international cell accounts for 20 per cent of the business for the hospital. For Max, the bulk of the patient inflow is from South Asia, Middle East and Africa. The developed world — North America and Europe — account for barely 5 per cent of Max's international patients.

Facilitation centres: Many Indian hospitals have set up facilitation centres abroad to highlight the advanced medical facilities available in India at cheap rates. These facilitation centres act as the first line of contact for patients who want to be treated in India. An international patient takes about 30-40 interactions with the Indian hospital before travelling to India. After assessing the medical reports, Indian doctors recommend what treatment is best for the patient.

Visa procedures: Unlike a regular travel visa, medical visas are issued on a priority basis. Medical visa is open to residents of all countries including Pakistan, Bangladesh, China and Sri Lanka, with a validity of one year. This is extendable under certain conditions, subject to approval by the home ministry.

Accommodation: These are usually guest houses that thrive around hospitals. Almost 80 per cent of the clientele comprise people travelling with the patient. Locals also rent out smaller rooms, at almost double the rentals.
Translators: Translators earn anything between Rs 500 and Rs 1,000 a day. In Delhi, most of the translators comprise students and refugees living in the city.

Hospitals: International patient centres are a part of hospitals. Patients are often seen with translators. Some hospitals even have in-house doctors from West Asian countries.

Chemists: Medical travellers usually buy medication for longer durations — sometimes up to one to one-and-a-half years. It is a common sight for medical shops around hospitals to sport signboards in Arabic.

Ethnic foods: To cater to international medical travellers, there are region-specific restaurants and food stores. Most of these are operated by refugees or students studying in India. Insurance: Bupa and Allianz provide international insurance packages that cover treatment in different countries.

Having treated 60,000 (both in-patient and out-patient) overseas patients in 2010, the Apollo group claims to have the biggest share of the medical tourism pie in the country. The group generated revenues of Rs 350 crore last year. Apollo says its hospitals in different cities have loyal clientele from different geographies. For example, Apollo Chennai attracts patients from Sri Lanka and Canada, and some from Bangladesh as well. The Apollo in Ahmedabad gets a lot of traffic from the UK. The Delhi Apollo gets most of its global patients from Africa and the Middle East, while Kolkata gets the bulk of the Bangladeshi patients. "Not a day goes by without a flight from Sri Lanka to Chennai carrying at least one patient for Apollo. Ditto for Kolkata and Bangladesh," says Shobana Kamineni, executive director, special initiatives at Apollo Hospitals and director of new initiatives at Apollo Munich Health Insurance.

In Dr Naresh Trehan's Medanta Medicity in Gurgaon, international patient inflow is about 15 per cent. "Countries like Afghanistan don't have basic treatment. In the Gulf, basic care is available but no specialised procedures can take place. We have our share of Iranians and Iraqis coming for specialised treatments," he says. According to him, Commonwealth of Independent States (CIS) have a lot of potential.

The Foreign Bases
If the trickle of medical tourists a decade ago has turned into a flood today, much of it has to do with the facilitation centres, the bases, and the tie-ups that these hospitals have developed in potential markets. All the big hospital chains have crafted focused strategies to attract patients from target countries.

Take the example of Apollo, which opened its first international centre in Oman in 2008. It now has three. By the middle of this year, it will have three more clinics in the African countries of Kenya, Tanzania and Ethiopia. It also has tie-ups with local hospitals, government agencies and doctors in African countries. It also plans to set up a hospital in Nigeria soon.

All these — the facilitation centres, clinics, and local hospital tie-ups — help in publicising and making things easier for the patient looking to go abroad for treatment. Their basic tests are conducted at these clinics and detailed advice given to them. Other staff help work out costs, apply for visas, etc. The centres are used by patients to refer reports to doctors back in India and get approval for medical travel.

Fortis and Max have also been working on broadly similar initiatives. Boolchandani says that the sales effort in these countries is focused on building brand familiarisation and educating the potential patients about the facilities in the hospitals. He organises regular outreach programmes in target countries. "Health camps are the most popular — that is, taking doctors from India to these areas on a regular basis and treating patients."

Then, there are tie-ups with local clinics to set up facilitation centres. These are run by locals of the particular city on a franchisee basis, but training and back-end support is provided by Max. "Tie-ups with non-government organisations (NGOs) or government organisations play a significant role as well," he explains. For example, the Afghan Red Crescent Society sends 20-30 patients a month to the Max facility.

A host of medical travel companies that have sprung up around the world also work with hospitals in India. Max centres are already present in Nigeria, Afghanistan, Bangladesh and Nepal, where the chain is a well known brand. By 2012, Max will add five more regional centres in Ethiopia, Zambia, Oman, Kenya and UAE.

Fortis has gone a step further in brand building by engaging with medical colleges in Africa. They provide for students to be trained under surgeons in India. Every year, batches of students come from Congo, Kenya and spend between 45 and 60 days working under a specialist from Fortis. "We tie up with ministries there. NGOs from African countries such as Uganda, Kenya and Ethiopia are sending us patients regularly," says Kapur. He adds that Rotary Club in Uganda, doing paediatric cardiac work, generally refers 30 to 40 children annually to India, mostly to Fortis. The chain currently has one facilitation centre in Nigeria.

By 2012, Kapur will add 11 more centres — five in Iraq, two in Russia with another two in Nigeria and one each in Ethiopia and Tanzania. "These are the growth markets," says Kapur. Fortis has five dedicated facilities for international patients across India with Delhi seeing almost 85 per cent of the patient inflow, while its other centres treat the rest.

Smaller hospitals, individual doctors and fertility centres do not have such an organised approach. But many of them get a fair amount of traffic through either word of mouth publicity or their Internet presence. In the city of Ahmedabad, a famous orthopaedic surgeon relies heavily on the million-plus population of Gujaratis scattered across the globe to popularise his business. "There are half-a-million Gujaratis in East Africa and another million in South Africa", adds Dr Vikram Shah of Shalby's hospital in Gujarat, who now has a chain of clinics and hospitals across India. "We don't do any marketing activities as such," says Dr Shah who has operated upon the Prime Minister of Kenya. He is expecting a 20-25 per cent growth in both patient inflow and revenue over the next few years. Dr Shah gets an average of 230 international patients per month in peak seasons — October-March — at his Ahmedabad hospitals. During the rest of the year, this number drops down to 130.

The doctor has set up two facilitation centres in Nairobi and Oman, respectively, about two years ago, and is looking at establishing presence in London, too. "It helps draw in a lot of patients and also provide assistance to patients within their country," says Dr Shah.

Agents, Translators, Food And Drugs
If the bases abroad help build the brand, there is a thriving population of service providers of every kind that has cropped up to help patients negotiate India and the Indian healthcare system. Take the case of S.K. Chibber, who works as a translator with Max Delhi. Originally from Kabul, he has been in India since 1991 and been working as a full-time translator and interpreter for the past three years at Max (New Delhi). For Afghan patients facing the language barrier, he is a godsend. He introduces me to Abdul from Kabul who is here for an ENT procedure. The 19-year-old patient, studying business management in his own country, is accompanied by his two uncles and a younger brother. Abdul is happy — today is his last day at the hospital. "A friend recommended India to me," says Abdul. A six-month visa took barely a day to be processed under the medical tourism guidelines, he says.

GLOBAL EDGE: At Dr Naresh Trehan's Medanta Medicity, international patient inflow is 15 per cent

NEW FRONTIERS: Shobana Kamineni, executive director, special initiatives at Apollo Hospitals and director, new initiatives at Apollo Munich Health Insurance. Apollo has the biggest share of the medical tourism pie in India

There are plenty of translators floating around, doubling as facilitation agents. A random Google search for medical travel assistants will throw up plenty of suggestions. One such name is of Syed Affan who offers translation services in Delhi to patients from Iraq for six years now. Though he has a presence on the Internet, the bulk of his clients come through referrals. "I have worked with many patients from Iraq, so my work is always referred to by patients who have visited me before," says Affan, who hails from Bihar and knows Arabic, English and Hindi. "I have a team of four boys across Delhi who help patients tie up with hospitals, guests houses, etc." The money is good, he says. If the patient spends, say, Rs 50,000 on a surgery, Affan says he might make as much as Rs 10,000 — partly from the patient directly and partly as a commission from the hospital. He claims that he works with both big hospitals such as Apollo and small medical tour agents such as Delhi-based Addi Meditour India. He gets 12-15 patients per month.

Translators and guides are not the only ones ready to make a business out of helping out home-sick international patients. Of the 40,000-strong refugee population of Afghans in Delhi, many have found careers in facilitating medical travellers — from renting out rooms, to working as translators/facilitators to opening up restaurants and departmental stores.

In Delhi's Lajpat Nagar area, old Afghan men accompanied by children and women are a common sight. The four-kilometre radius has a record number of chemists — all with signboards in both English and Farsi. And most shopkeepers speak a smattering of Farsi. There are also eating houses set up by immigrants who serve ethnic food and have become support bases for new patients. Suresh Medicos in Lajpat Nagar opened about a year-and-a-half ago, and does brisk business from patients from the Middle East. He even offers discounts to patients who are willing to buy six months, or a year's supply of drugs.

In Ismayil Khan's Kabul-Delhi restaurant, a dedicated client base of Afghans stops by through the day. They range from permanent residents to students to off-course medical travellers — "I get 70 per cent Afghans, rest are Iraqis or Iranians". Ismayil, too, is banking on the sudden thrust the region has seen because of medical travellers. He moved to India in 2007 and opened his restaurant in late 2009. Since then he has seen no dearth of food lovers.

NOSE JOB: 19-year-old Abdul from Kabul had a nasal operation at Delhi's Max hospital. His brother (right) and two uncles travelled with him to India (BW pic by Tribhuwan Sharma)

And then there are the guest houses, as well as landlords who rent out rooms and apartments to medical travellers for medium
to short term.

Other parts in Delhi cater to Nigerians and other African nations, while still others are hangouts for people from the CIS countries.
For instance, Delhi's Karol Bagh with its multitude of guest houses. Then, there is the Khadar village near Sarita Vihar, which is replete with diagnostic centres as well as temporary accommodation.

Of course, as all these are unregulated, there is plenty of scope for unscrupulous touts to thrive as well. They often prey on the unsuspecting patients who have not come through a hospital facilitation centre in their country, and whisk them to private hospitals and nursing homes for a bigger commission. Big hospitals such as Apollo and Fortis say they are aware of these people — but are helpless to do anything about them.

The Economics Of Medical Travel
International medical travellers are good for the corporate hospitals because these people often spend more for the same procedure than Indian patients. That is because medical procedures are often sold as packages, which include consultation in home country, facilities within Indian hospitals (mobile phone, accommodation, etc.) and could therefore be anywhere between 20 per cent and 30 per cent higher than the cost that an Indian patient would bear.

Down south, patients arrive in large numbers from Bangladesh and Sri Lanka at the Manipal Hospital in Bangalore. Dr Nagendra Swamy, group medical director at Manipal Hospitals, explains the economics of the business. "There isn't a lack of patients within India and some of our hospitals are 100 per cent occupied. But international patients often occupy high-end beds and are therefore a clear revenue generator for the hospitals." Dr Swamy does some quick math and gives me an example. A $2,000 procedure for Indians on a single room basis would cost an international traveller about $3,000 ($1,000 extra) as part of the package or 20-30 per cent hike in cost.

"The whole economy of this system will only be successful if it helps hospitals get higher revenues for the same bed and procedure. That can help upgrade the facilities of the general ward," he says. But Dr Swamy says his international patients are different as they come mostly from Bangladesh and Sri Lanka and do not pay significantly more than what Indian patients do.

LIFELINE: Imam David Abdul Rahim with his brother and wife at Delhi's Apollo hospital. He travelled from Nigeria for a kidney transplant (BW pic by Tribhuwan Sharma)

Though the Indian medical treatment costs are reasonable by developed world standards, they are often a burden for the international people who do come for treatment. Ali Ahmand Nakuma from Kabul is in India for a nasal operation for his daughter. He has had to sell off some of his valuables to fund the trip and the treatment. He is in the army in Afghanistan but has received no financial aid. "India is very expensive, I do not get any benefits from the government," he conveys forcefully through his translator.

He has taken temporary accommodation in Kabuli hotel in Delhi's Lajpat Nagar area, run by local Afghan refugees at Rs 1,600 a day. While there are plenty of patients who go back happy with their treatment, there are others who face complex medical procedures. Abubakar Imam from Abuja in Nigeria chose Apollo because "Apollo is a household name in Nigeria". Placed comfortably in a suite on the 6th floor at Apollo's Delhi facility, he has accompanied his brother, Imam David Abdul Rahim who needs a kidney transplant. He has been in India for two months now. A surgery that was to take one month and $10,500 has gone beyond its stipulated time limit. A kidney rejection (every transplant runs the risk of 10 per cent rejection) has delayed the process by another month. The hospital has found another donor to ensure a quick procedure. But for the patient, this only means additional expenditure  in terms of medical bills and cost of accommodation for the family, pushing the total expenditure to eight times its estimated cost. But the patient is livid at the uncertainties of his health. "I came here with $50,000 and all is spent. I've asked for another $30,000 from my home town," says Rahim, who has political connections back home.

But such stories are relatively rare — and the bigger chains take great care to sort out problems faced with the medical travellers. But it is still a work in progress — and the industry will take some time to settle down.