Strategies for mitigating the effects of a pandemic on Indian medical tourism

Dixita Kapadia, Prerana Dongre, Ritika Mahadevan. Strategies for mitigating the effects of a pandemic on Indian medical tourism. Cardiometry; Issue 20; November 2021; p. 144-150; DOI: 10.18137/cardiometry.2021.20.144150; Available from:

In today’s era of pleasure or business travel, medical tourism has created a new avenue for the health-

144 | Cardiometry | Issue 20. November 2021

care industry in an innovative way[1]. The patients, as medical tourists, have the option of domestic and international travel to acquire the highest quality clinical expertise at affordable treatment costs. Based on the pattern of travel, medical tourism classifies as inbound, where a patient travels from a foreign country to the home country and intra-bound or domestic, where a patient travels within the country for medical treatment[2].

It is evident from the statistical data that 11 million people travel every year to seek medical care from their country, which is around 1% of the world’s tourist volume[3]. Among tourists traveling for medical treatment, 95 % of patients travel for therapeutic or healing treatments, such as cardiac treatments, dental procedures, cosmetic surgeries, orthopaedic prosthesis, cancer treatments; and remaining to travel for wellness tourism, including rehabilitation, yoga therapy, stress reduction, and alternative medicine[4].

The global market for medical tourism was estimated at US$16.761 million and projected to grow to US$27.247.6 million by 2024, achieving a CAGR of 8.5 % by 2019-2023. Reports by FICCI and IMS Health India indicated that Indian medical tourism has nearly 18% of the international medical tourism market share[5]. As per the data of the Ministry of Tourism, the Indian medical tourism industry could be worth $9 billion, and it further estimated that Indian medical tourism would account for 20% of the international market share by 2020[6]. However, in 2020 due to a sudden outbreak of COVID-19, medical tourism has declined significantly due to lockdowns in most countries to reduce the spread of infectious disease[7]. Before COVID-19 world has experienced numerous pandemic outbreaks like severe acute respiratory syndrome outbreak (SARS) in the year 2002-2004, in 2009-2010 Swine flu pandemic, and 2012 Middle East respiratory syndrome (MERS)[8]. None of the past outbreaks declined the progression of the global tourism industry in the long term, except SARS and the current pandemic of COVID-19. The SARS affected global tourism by -0.4 %, whereas the COVID-19 affected more adversely with -44.4 % of the rate in the first four months of 2020[9]. Before the COVID-19 outbreak, the factors impacting medical tourism were modern technology, quality healthcare, visa accessibility, affordable cost, and very few efforts made for considering the possible impact of the pandemic on medical tourism[10].

Accordingly, the present paper aims to study the factors affecting medical tourism and develop a SWOT analysis to foster strategies for mitigating the effects of a pandemic on Medical Tourism [11]. Further present paper aims to apprehend the impact of quotes such as “Health is wealth” and “Prevention is better than cure”. Yoga, Ayurveda, and Indian ancient cultural practices more emphasized during COVID-19 for the growth of Indian wellness tourism[12].

Methodology

Descriptive research carried out for the study. The literature search was performed using the keywords: medical tourism, wellness, pandemic, and COVID-19. The studies presenting trends in medical tourism, the effect of the pandemic diseases, and the correlation between medical tourism and the pandemic have been taken into consideration. Data obtained from the relevant research papers and administrative records used for further review[13]. Information and the statistical data on the pandemic diseases are taken from the World Health Organization (WHO) and Centres for Disease Control and Prevention (CDC) website. Also, the tourist data obtained from the official website of the Ministry of Tourism India, Bureau of Immigration India, and Organization for Economic Cooperation and Development (OECD)[14].

Results

Global Medical Tourism Industry

The medical tourism industry is now promoted at a global level. Quality care and affordable health services are a principle phenomenon for the industry. Medical tourism analysts’ claim that the international market for medical services enhance customer options, encourage competitiveness amid hospitals, and enable clients to access high-quality healthcare treatments across the globe[15]. Pessimists put up questions related to the quality service and safety of patients, confidentiality of patient records, legal action when patients harmed when providing hospital care in foreign countries, and damage to the national healthcare systems of the host country[16]. The development of a competitive global market for health services has important implications for health insurance, health service provision, and the expansion of consumerism in the healthcare industry. The serious threat to the expansion of the medical tourism sector is the pandemic diseases, especially when they are infectious such as currently COVID-19 pandemic[17].

As per World Health Organisation (WHO) report, around 215 countries and more than 20 million people have been infected with COVID-19 worldwide. It is an infectious disease that spreads through coming in direct contact with the infected patients and also by droplets from the contaminated surfaces. Preventive measures should remain more focused on reducing the spread of infection like keeping physical distance, self-isolation, and following proper sanitation meth-ods[18]. As a result, the quotation of “prevention is better than cure” has been followed by most countries by imposing lockdowns and travel bans to reduce the spread of the disease. It stated that some countries restricted the entry of travellers from the affected areas and altered immigration rules; some have ordered the complete lockdown that no resident will travel to other nations. These restrictions and concerns of the disease have a major influence on the tourism sector and are anticipated to have a critical effect on medical tourism[19].

Even though many hospitals and clinics would have more patients and revenues increased by local clients but, the hospitals that are more dependent on international medical tourists strive for their finances. The hospitals must emphasize more on domestic medical tourists for providing quality care in this sce-nario[20]. In the hospital sector, the representation of quality services goes beyond the simple application of quality management to it as a whole. The implementation of quality improvement for medical tourism is very complicated as it entails individuals from different countries with diverse cultural backgrounds and needs. However, a healthcare organization can offer a wide range of services under one roof at an affordable price that can increase its revenue[21].

Medical Tourism Industry In India

In India, medical tourists travel from both developed and emerging countries. The patients travel from developed countries due to less waiting periods and affordable treatment costs and from the developing and underdeveloped countries because of the presence of the advanced healthcare provisions in India[22]. Reports show that India gives a competitive price benefit with one-tenth of the charge of Europe and the US.

Medical tourists also travel to India for wellness and alternative medicine like the AYUSH sector. Increased awareness related to the well-being of individual and alternative healthcare have enhanced the Indian wellness tourism.

Medical tourism is a complex and dynamic industry and therefore faces various challenges. There are following barriers/concerns for India as a tourist destination mainly for medical tourism:

• •    The perspective of International Patients as India has inadequate healthcare facilities, a lack of standardized processes, complicated visa procedures, and an unsanitary environment.

• •    The infectious pandemic diseases increase the uncertainty and apprehension among individuals, and this leads to the disruptive changes in medical tourism.

• •    There is still a shortfall of government initiatives, as there are no specific rules and regulations, variations in taxes, and lack of investor-friendly policies.

• •    Insurance related issues such as underdeveloped health insurance sector, fraud, and denial of reimbursement by international health insurance companies.

• •    Other challenges include quality accreditation of hospitals and laboratories, training and development of healthcare professionals, and a customer-oriented strategy.

SWOT analysis on Indian medical tourism

Strengths- India have affordable treatment costs. As per the American Medical Association study, the fees of therapy in India are almost three times lower than in western countries, such as the UK and the US. Qualified healthcare staff and advanced healthcare services including transplantation surgery and stem cell treatment are available. Many Indian hospitals and physicians have an international reputation. International students who come to India for their education can promote the Indian health services in their home country. India has its ancient wellness and medical strengths viz. Ayurveda, Unani, Yoga, Siddha.

Weaknesses- There is a shortfall of government initiatives and a regulatory system in India for medical tourism. Public healthcare funding is low in India as compared to other nations. Pricing strategies for different hospitals lack uniformity. There is less association between airlines, the hospitality sector, and the healthcare sector.

Opportunities- In particular, the awareness and demand for preventive health and wellness services are increasing globally. As India has its inherent strengths, this would be a great benefit for it. Developed countries have long waiting times so; countries like India can provide treatments in short waiting times. Emerging and underdeveloped nations have limited healthcare facilities so; India can deliver advanced healthcare treatments.

Threats- Healthcare professionals have a high brain drain. As per the Organization for Economic Cooperation and Development, nearly 69,000 physicians and 56,000 nurses worked in the UK, Australia, Canada, and the US in 2017 are Indian. Competition from other nations is increasing such, as Singapore and Japan. All health insurance companies do not provide coverage for international health services. Pandemic infectious diseases such as COVID-19 are currently a serious threat to the industry.

Medical Tourism and Economy

Medical tourism fosters direct foreign exchange earnings and raises the economy of the nation. It also empowers healthcare businesses and increases the job opportunities for the citizens. It enables the expansion of other related sectors, like pharmaceuticals, health insurance, tourism, wellness, and medical devices.

Currently, as a consequence of COVID-19, this industry has suffered significantly. Due to the lockdowns in most countries, tourist arrivals have dropped sharply, and foreign exchange earnings have therefore declined tremendously. The following graph shows the growth rate of international tourist arrivals and foreign exchange earnings through tourism. There is a significant reduction due to COVID-19.Figure 1 shows the growth rate of International Tourist Arrivals and the growth rate. It is, therefore, crucial to develop strategies to mitigate this impact at present and also to be ready for any future infectious pandemic diseases.

Components that mitigate the adverse effects of a pandemic

on Indian medical tourism

The following suggestions set out India’s potential path to take the lead in medical tourism.

Part of Government

• 1.    As the airport is the starting point of contact, the facilities at the airport must be updated to take all

• 2.    Digital connectivity needs to strengthen to provide extensive support for healthcare delivery. The use of telemedicine is encouraged to the extent possible for overseas patients. Clear guidelines for telemedicine must issue to all healthcare providers.

• 3.    The medical visa process, the selection, and registration for healthcare services is challenging, so efforts should be made by the authority to make it simpler and less tedious by marketing and financially reinforcing the medical tourism companies. These help to captivate more international medical tourists and make India the leading medical tourist destination.

• 4.    In addition to medical and surgical care, the emphasis should be on the preventive and wellness ancient practices of India like the AYUSH sector and naturopathy. These wellness practices boost

• 5.    Rules for health insurance companies relating to the provision of international insurance plans must consign. These should cover not only modern medicine but also the costs of digital consultations, wellness programs, and travel expenses.

• 6.    The authority should set up a body to regulate medical tourism. These promote India’s healthcare services through global marketing and also address the challenges of the international healthcare industry. The main agenda for such a body should be as follows:

—•— International Tourist Arrivals Growth Rate

■ ■ Foreign Exchange Earnings Growth Rate through Tourism

Figure 1. Graph showing the growth rate of International Tourist Arrivals and the growth rate of Foreign Exchange Earnings through Tourism (Oct’19-Mar’20)Data Source- Ministry of Tourism, India the precautionary measures to obstruct the spread of the COVID-19 pandemic. The rapid test kits and thermal testing facilities must be available at all the airports. The authority must mandate physical distance travel in flights as part of the preventative measures. Tests were carried out for every suspected individual or traveller from the affected countries. All these preventive measures reduce the chance of spread of infection and also increase the credibility of the host country.

the immunity of individuals and thus reduce the chances of infection. These not only prevent the current spread of disease but also certainly protect the individuals for any future infections. There should be the creation of holistic centres in healthcare providers such as the meditation room. This additional care services uplift the economy by increasing the revenues of the wellness industry.

• •    Creating Indian Medical Tourism Brand in Abroad

• •    Encouraging Inter-sectorial Collaboration

• •    Information Circulation by Technology

• •    Service Standardization

• 7.    The Government may facilitate additional services, such as airline and hotel ties, the availability of translators, multi-cuisine kitchens, and leisure activities. These make the experience of patients much better and thus make India a leader in the medical tourism sector.

Role of Private Sector

To combat the rising competition and infectious pandemic diseases in the medical tourism market, private hospitals and laboratories in India must strictly follow international quality service standards such as Joint Commission International (JCI) Accreditation and College of American Pathology (CAP) Accreditation. Further emphases give to proper sanitation practices and to maintain physical distance at work. Web or application-based appointments and digital consultations should be facilitated as a prospective triage before the medical tourists arrive for treatment and follow-ups.

As a part of the marketing plan for various healthcare services, the tours and travel industries and healthcare providers can have packages, including transportation, lodging, and cost of treatment. They can carry out joint operations to improve medical

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tourism. International institutions tie-ups promote medical tourism globally. It may be a joint venture between insurance companies or between hospitals. For additional revenues, other facilities of the wellness sector as meditation and yoga set up.

Currently, it is difficult to have international medical tourists due to the COVID-19 pandemic. So in such a situation, the private healthcare sector should focus on providing telemedicine to international patients. Also, emphasize more on domestic medical tourism and increase the awareness for ancient medicine and wellness systems to boost the immunity of the community.

Discussion

India is one of the fastest booming medical destinations around the globe; this is a novel model to improvise the existing medical tourism system by targeting international students in India. International students arrive from 164 nations around the world. According to the HRD Ministry report, the students in India enrolled for higher education are a total of 47,427 for the year 2018-19. Maximum international students arrive from proximate countries such as Nepal at 26.88 %, accompanied by Afghanistan at 9.8 %, Bangladesh at 4.38 %, Sudan at 4.02 %, Bhutan at 3.82 %, and Nigeria at 3.4 %. Therefore by establishing a novel Model that targets the International Students traveling to India for their education expands the scope of Medical Tourism.

The Model covers travel, accommodation, treatment, and post-treatment care. In the initial phase, the target is the International Students who travel to India for education and thereby slowly expanding and familiarizing the Global Market about the Model shown in Figure 2. Special concessions need to provide to the immediate family members of the students and referrals. The Model website includes details of treatment available and packages.

Ayurveda, Unani, yoga, naturopathy, and Siddha are another major inherent factor in India used to improve medical tourism. These systems of medicine focus not just on diseases but also the well-being of patients, their lifestyles, and the environment. These also help in boosting immunity, and in the current crisis, this can be a significant advantage to focus more on the Ayush sector. Ayurveda has been using natural herbs for the prevention and cure of diseases for thousands of years. It places more focus on pre- 148 | Cardiometry | Issue 20. November 2021

Figure 2. Process of the Model (Flowchart)

vention and promotes health conservation by proper attention to equilibrium in the right mindset and nutrition. Unani is a robust system that offers preventive and therapeutic health care. This system bases on scientific concepts and multidisciplinary ideas of wellness and cure. Yoga is the kind of practice offering mental and physical well-being to the individuals. It refreshes and detoxifies the system and strengthens the immune response of the body. Naturopathy focuses on balanced living and supports assisting the human body to eliminate disease causes. The Siddha system combines both spiritual and physical elements and treats the individual as a whole. All of these traditional health services need to take into consideration carefully to encourage domestic and international medical tourists and generate more revenues. India is known to have a rich heritage of the ancient medical and wellness system, and this attracts numerous foreigners to the country.

Conclusion

The medical tourism sector is a continuously developing and growing industry in India. But there are various obstacles experienced by the Indian medical tourism industry, all the prospective to expand to number one position to attract international medical tourists, by working on its problems and improving service quality and maintaining it all the time. Pandemics such as COVID-19 are creating a significant shift in the medical tourism sector. Collectively, the goal is to learn from this global catastrophe and promote the transformation of the medical tourism industry. The part of the Government of India (GOI) is vital for the medical tourism growth. The government should take proposed measures and act as a board of control and enabler of private capital expenditure in healthcare. Since Medical Tourism is a combination of the healthcare and travel industry, both industries should enforce preventive measures comprising physical distancing and practicing sanitation. The use of telemedicine can help in strengthening the communication and information industries to reduce the contrary effects of COVID-19. Setting up the emerging board helps to reinforce and endorse medical tourism. Pandemic situations promote nationalism, so the medical tourism business should focus not only on international travel patients but also on domestic travel patients. Certainly, this way the medical tourism can further contribute to the country’s economic development during this and any future pandemics.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest

None declared.

Author contributions

The authors read the ICMJE criteria for authorship and approved the final manuscript.