Indian medical tourists: Where do they all come from?

Ms Asin: a pretty Indian actress

Countires aspiring to be the global hub of medical tourism always trumpets on how people from developed countries (translate: USA/EU) are lining up at their health care facilities. India is a case in point.
The International Welllness and Healthcare Travel Association (IWHTA) however beg to differ. They recently analysed where Indian medical tourists come from.
Their analysis confirms that although Europe and the USA are often mentioned as a source of medical tourists, together they only account for one in ten travelers. The analysis provides the following breakdown:
• Bangladesh/Nepal/Sri Lanka 19%
• Iraq 18 %
• Middle East 16 %
• Africa 9%
• Afghanistan 9%
• Europe 6%
• USA 4%
• * Non resident Indians from all countries 22%
Naresh Jadeja of IWHTA also analyses the current position of India:
• The last five years has changed Indian hospitals and services by adding thousands of hospital beds and a number of world-class hospitals with state of the art health care and technology.
• Many Indian hospitals are not attracting international patients not because they are not up to the mark but because they are running at their capacity as both health insurance and the healthcare demands of India’s middle class rocket.
• Although the Indian health care industry is advertising less it is enjoying a substantial share of international patients from around the world. More than 580 multi specialty hospitals and over 400 single specialty clinics in India are treating international patients.
• A key market is non-resident Indians who visit their home town every year or every other year and opt for diagnostic and wellness tourism activities as it is time consuming and costly in their countries. Hospitals promoting executive checkups are trying to build trust through feel good visits to show people their quality commitment and technology.
• IVF and infertility procedures are offered by hundreds of clinics in India.
• Alternative medicine such as yoga and ayurveda is very popular and wellness treatments are attracting many visitors. Hotels with these options and medical spas are in big demand.
• Dental tourism is a growth area.
• There are two totally different types of patients going to Indian hospitals. Those from less developed countries do not expect any added services or soft skills from medical staff, but those from developed countries do expect this and more.

New Influenza Vaccine Guidelines for 2010-2011

From the CDC:

There are some significant changes in this flu season's recommendations that healthcare providers and clinicians should be aware of before beginning flu vaccination efforts.

On July 29, 2010, the CDC's ACIP issued recommendations for everyone 6 months of age and older who do not have any contraindications to vaccination, to receive a flu vaccine each year, beginning this flu season. ACIP recommends that children 6 months through 8 years of age receive 2 doses of the 2010-2011 flu vaccine with a minimal interval of 4 weeks unless they have received:

• At least 1 dose of 2009 H1N1 flu vaccine last season; and
• At least 1 dose of seasonal flu vaccine prior to the 2009-2010 flu season or 2 doses of 2009-2010 seasonal flu vaccine.

If a child has fulfilled both of these requirements, they only need 1 flu vaccine.
Also important to note within the new recommendations is information about a newly approved vaccine, Fluzone High-Dose, for those 65 years of age and older, which simply adds another vaccine option for this group. Those 65 years and older can choose a standard-dose trivalent flu vaccine (15 mcg per strain) or the Fluzone High-Dose vaccine (60 mcg hemagglutinin antigen per strain).
Other additions to the recommendations include information about newly approved flu vaccines, as well as previously approved vaccines with expanded age indications.

A new inactivated flu vaccine, Agriflu, has been approved for people 18 years of age and older. Fluarix is now approved for use in those 3 years of age and older, while Afluria is available for use in those 9 years of age and older. High-risk children 5 through 8 years of age are recommended to receive Afluria ONLY if all other age-appropriate alternatives are unavailable.

The 2010-2011 flu vaccine is made in the same way as past flu vaccines. Over the years, hundreds of millions of people in the US have safely received seasonal flu vaccines. This year's vaccine will protect against the 3 main viruses that research indicates will cause the most illness. This season's flu vaccine will protect against 2009 H1N1, an A- H3N2 virus, and a B virus.
Since the seasonal vaccine will protect against the 2009 H1N1 virus, 2 different flu vaccines will not be necessary this season.

While everyone should get a flu vaccine each flu season, it's especially important that certain groups get vaccinated either because they are at high risk of developing serious flu-related complications or because they live with or care for people at high risk of developing flu-related complications. They are:

• Pregnant women;
• Children younger than 5, and especially children younger than 2 years;
• People 50 years of age and older;
• People of any age with certain chronic medical conditions such as asthma and diabetes;
• People with immunosuppression, whether due to illness or medications;
• People who live in nursing homes and other long-term care facilities; and
• People who live with or care for those at high risk for complications from flu, including:
  
  
  1. Healthcare workers
  2. Household contacts of people at high risk for complications from the flu
  3. Household contacts and out of home caregivers of children less than 6 months of age (no vaccine is approved for children younger than 6 months, as these children are too young to be vaccinated)

Indonesian “international” hospitals are banned

The Health Ministry of Indonesia has banned local hospitals from branding themselves as international hospitals. The ministry's Farid W. Husein says, "By August this year, hospitals must have removed the word international from their brand unless they are internationally accredited." The Health Ministry added that ten local hospitals have planned to apply for international accreditation this year with The Joint Commission International. The ministry will pursue any hospital using global or international labels to which they are not entitled.

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A number of the country’s private hospitals are now known by a new name following the government ruling barring hospitals from using the often misleading attributes: international, global or anything else referring to worldwide networks or high quality of health care. The Bintaro International Hospital (RSIB) has adopted its new name, Bintaro Premier Hospital. The hospital argues that the stripping of the international attribute does not necessarily mean a lower quality service, “The change of the name has been carried out because we have to meet the prevailing regulations.” The hospital formerly known as Omni International Hospital in Serpong, Tangerang, Banten, dropped its middle name, now renamed Omni Hospital.
Dr. Supriyantoro at the Health Ministry comments, “The existence of such international attributions did not guarantee the quality of a hospital’s service to the public.” The use of those attributes has been widely criticized by the public amid reported cases of malpractice involving doctors from several so-called international hospitals. In one recent case Prita Mulyasari was imprisoned and fined by a civil court for allegedly defaming an international hospital following complaints made by her via email over receiving poor medical services. The case sparked widespread protest and led to an unprecedented campaign over social networking sites such as Facebook and Twitter to raise money to help Prita pay off the fine. Public pressure eventually saw the court acquit the case, while the hospital has not yet retracted its lawsuit against Prita.

Dadang M. Epid of South Tangerang Health Agency has called on the hospitals that have stripped their international names to inform the public of the change, “With the announcement, hopefully, there will be no more misunderstanding among the public. People will no longer regard those hospitals as hospitals operating under international standards.”

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Thailand’s medical tourism: Fighting Sisters

Wat Rong Khun - White Temple

Thailand’s medical tourism had been badly battered by troubles earlier this year, particularly in and around Bangkok. Phuket by the way suffered very little and is keen to promote itself as a safe and affordable destination, even at the cost to local rival Bangkok.

“With droves of expatriate foreigners having moved out of Thailand, hospitals like Bumrungrad Hospital and Bangkok Hospital Medical Center are working on solidifying their home base and focusing efforts on bringing back local Thai residents, who often view these high end private hospitals as too expensive. Both hospitals continue to draw medical travellers from surrounding countries like Burma, Bangladesh and Indonesia, and from the Middle East. Thailand as a medical destination was not put on the medical travel map by government policies, it was the top hospitals, and they will continue to do this, with or without official government support.”

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Medical and healthcare providers on the island of Phuket can expect to get a large slice of the 402.9 billion baht that the Thai Ministry of Health expects Thailand’s medical tourism industry to take over the next five years, says Dr Wiwat Seetamanotch of Phuket Public Health, “Over the past five years, Phuket has enjoyed great success in health services provided to tourists and earned a huge amount of money. In addition, health services here are cheaper than in neighboring countries.”
The MoH, according to its current five-year plan for 2010 to 2014, expects medical tourism to generate 400-billion-baht .The previous plan, for 2004-2008, concentrated on providing medical services to patients from abroad. Under that plan, the MoH aimed to make Thailand the centre of excellent healthcare in Asia through treatment businesses, health supplement businesses, health products and Thai herbs. The current plan targets developing the same businesses and products, but adds more services in the realms of Thai traditional medicine and alternative medicine. The move follows Thailand’s enjoyment of huge growth in its medical tourism over the past decade.
 According to MoH statistics, although these are only estimates based on information from hospitals and include holidaymakers, business travelers and expatriates, 550,161 foreign patients received treatment or healthcare in Thailand in 2001, while in 2007 that number had swelled to 1,373,807. Most were Japanese, followed by Americans and Europeans. Although key markets claimed are Japan, Australia, New Zealand, USA, Myanmar and Indonesia, in reality, 80% come from South-East Asia including Japan and Indonesia. An estimated 70% of the foreign patients during that period were medical tourists, with 25% being expatriates and less than 5% being tourists. The most popular health services during that year were health checks, heart operations, knee replacements, cardiovascular surgery, cosmetic surgery, gender reassignment surgery, dental care and Lasik corrective eye surgery.
Dr Wiwat expects the number of medical tourists to Phuket to increase dramatically in the coming years, “In addition to three government hospitals in Phuket, there are also three private ones that are recognized as international standard.”

Wat Rong Khun

Bangkok can regain its top place in Thailand, but it will require more work than the authorities are currently putting in: “Whether Bangkok can restore its prominence as a medical destination hinges on how the Thai government, specifically Tourism Authority of Thailand (TAT), acts to promote Thailand for medical tourists in the coming year. Sustained and cohesive promotion efforts are not likely to happen soon. While TAT has been working on a medical tourism marketing plan for almost a year, it has faced leadership changes and budget cuts. It has had to put other priorities, namely bringing back tourists - any tourists - ahead of promotion of medical travel and health tourism. TAT has, however, announced that it will continue promotion of Thailand's spa, wellness and medical services in the Middle East, but not medical tourism. The private hospitals have their own problems.”

Without coordinated promotion of medical tourism by government and trade groups, will hospitals like Bumrungrad International or Bangkok Hospital Medical Center be able to maintain their position within the global or even regional medical tourism industry? Will Bangkok lose out to the northern city of Chiang Mai or the tropical island of Phuket?
“What remains of Thai medical tourism will continue to favor Bangkok. Phuket has daily international flights by regular and discount airlines to dozens of regional cities, and it has lovely resorts - now mostly empty. But its two private hospitals, Phuket International and Bangkok Phuket, are considered by most local expat residents a clear second choice, and prefer flying into Bangkok for care. The two private hospitals are considered expensive, with high hospital costs and doctor fees.”

Phuket is to be the home of the country’s first purpose built “Health Promotion Hospital”, co-funded by the Chinese government. The Kamala Public Health Center will incorporate traditional Chinese medicines into its array of medical services. To be completed next year, it will initially offer health checkups and traditional Thai massages to both Thais and foreigners.

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Why do medical tourism businesses fail?

 The internet and the media in general often report stories of (purported) medical tourism business success, but remain silent when it comes to the reporting of failures. People who have developed a medical tourism business; for the most part means that they became “medical tourism facilitators”. Stories of people and businesses who decided to enter the “billion dollar medical tourism market” by addressing and targeting the patient from abroad. These are typically medical services providers who have an existing and well established domestic healthcare business or typically medical tourism facilitators who may be new to the healthcare sector.

Inspired to enter the medical tourism and medical travel sector by what they read on the internet, what they heard at conferences or based on the advice of various industry experts and consultants.

Their experience of entry into the market range from disappointment to stories of sorrow and woe. The answers are clear and simple:

• In determining the opportunity, these failed market entrants may have overestimated the size of the market (both current and potential). Some may have got this badly wrong.

• These failed market entrants to medical travel tended to be ill equipped aspirants who knew about but did not fully understand the market sector. And to their detriment, placed too much faith and trust in the knowledge and understanding of others.

• Some failed market entrants got their assessment of current and potential market size right, but they failed to consider the number of pre-existing, well qualified and established industry players.

• And of course, some perhaps did not factor in the risks of entering international markets and the effect that national and international events can have on a business which is dependent on international travel. Recent examples include drug related violence in Mexico, civil unrest in Thailand, and the NDM- 1 “superbug” story emanating from India.

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The decision to enter the international medical travel either as a facilitator or a medical services provider should take into consideration not only the size of the market, but also the number of industry players, especially those who are well equipped, in terms of capital, financing and knowledge and understanding.

In a market with many players, a good idea may become a bad idea.

The competition is becoming more aggressive and sophisticated, and often has deep pockets. And which is also the reason emphasizing the need for formal “sector-specific” executive education for those contemplating going into the health tourism business (from empiricism to professionalism).

It’s been argued that contrary to simplistic thinking, the growth of medical tourism, in isolation, (as opposed to health tourism, which includes medical tourism) will not experience the “explosive growth” predicted by some consultants and experts who fail to appreciate how healthcare delivery and consumption actually works.

Medical travel destinations which set out to become the “leading destination for medical tourism” on the basis that they were cheaper and better than domestic facilities and providers are now experiencing the effect of the “West’s Revenge”. This has been compounded by the effects of the worldwide recession. Again, contrary to the simplistic thinking of some commentators who argued that recession would drive more and more patients abroad for cheaper treatment, this has clearly not been the case; medical tourism and healthcare businesses in general are being hit by recessionary factors the same as other international markets and businesses.

White House is Writing Off Small Medical Practices?

Physicians Say White House Should Not Write Off Small Practices

In a newly published article, the White House is advising physicians to accept a life in Big Medicine — as a hospital employee or member of a large group practice — in the wake of healthcare reform.
Some leaders of organized medicine, however, are objecting to the government message.
"We're not ready to write off the small practices," J. Fred Ralston Jr, MD, president of the American College of Physicians, told Medscape Medical News. "We think there needs to be more than one delivery model."
Dr. Ralston and Dr. Williamson were responding to an article by 2 White House officials and 1 ex-official about the implications of healthcare reform.
"The economic forces put in motion by the [Affordable Care] Act," the authors write, "are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups." Physicians who embrace the changes and opportunities created by the law "are likely to deliver the greatest benefits to their patients, the health system, and themselves" and "will be rewarded in the future payment system."
What does it mean to embrace "vertical organization?" This business catchphrase refers to enterprises with a hierarchal structure and centralized management. An integrated delivery system that owns hospitals, medical practices, and other healthcare services is a prime example. Other examples are the military and the federal government.
The growth of vertical healthcare organizations, as well as large, independent group practices, has slowly dismantled medicine as a cottage industry. The percentage of physicians in solo practice declined from roughly 41% in 1983 to 25% in 2007 - 2008, according to data from the American Medical Association. According to an oft-quoted study from the Center for Studying Health System Change, the percentage of physicians who are solo practitioners or are practicing in groups of fewer than 6 physicians fell from 53% in 1996 - 1997 to 42% in 2004 - 2005.
The White House officials say healthcare reform will further the trend toward aggregation. The new law lays the groundwork for financially rewarding providers based on the quality of the care they render through accountable care organizations (ACOs) and patient-centered medical homes. ACOs consist of physician practices and hospitals that take joint responsibility for meeting performance measures for quality and cost, and they either earn bonuses or incur pay cuts depending on how they perform as a group. In a medical home, a patient receives holistic, long-term primary care from a multidisciplinary team usually led by a physician, with insurers paying extra for coordination of care with outside providers.
In these new models, there needs to be information technology — as in electronic health records — and administrative personnel to "track quality measures, account for and manage shared financial incentives, and oversee care coordination," the authors write. Accordingly, the healthcare system will gradually organize itself around either hospitals or physician groups.
Past Experience With Hospital Employment Not Encouraging
Dr. Ralston of the American College of Physicians points to the unhappy experience that physicians had when droves of them went to work for hospitals in the 1980s and 1990s. Many of those marriages broke up.
"Most doctors who were employed by hospitals found the arrangement lacking," he said. The well-being of medical practices took second place to the well-being of the hospital, and the loss of independence proved painful.
Physicians in small practices can enjoy the benefits of larger organizations without giving up their independence, Dr. Ralston said. Computer technology, for example, can allow small rural practices to share common employees who tackle quality-improvement chores. And computer technology allows independent practice associations (IPAs) to function as group practices. A case in point, said Dr. Ralston, is the Mesa County Physicians IPA in Grand Junction, Colorado — a community celebrated for improving patient care while lowering costs. Healthcare reformers, he said, need to gather more evidence on how large and small organizations perform in the new framework of quality goals and financial incentives.
"I agree wholeheartedly that the law will push physicians into larger groups," said Dr. Williamson, who also is a spokesperson for the Coalition of State Medical and National Specialty Societies, which campaigned against the Affordable Care Act. "I don't think that's the role of the federal government to be doing that."
Dr. Williamson said the law will only add to the regulatory burden that has forced small-practice physicians to seek refuge in a hospital or mega-group. Many physicians, he predicted, will not accept the new paradigm and will instead leave patient care, leaving medicine even more short-handed.
He conceded that some vertical organizations in healthcare, such as the Veterans Health Administration, perform well. "But we need pluralism," said Dr. Williamson, a member of a 3-physician practice. "We need soloists as well as groups."
"The game is not over for small practices," Dr. Ginsburg told Medscape Medical News, "but it's over for small practices operating in a bubble on a piecemeal basis, ignoring the rest of what's happening to their patients. They can't just be cottage industries."
Echoing Dr. Ralston, Dr. Ginsburg said IPAs show small groups a way forward. "IPAs are keeping medical practices viable in California," he said. He noted that their record of success has occurred in a state where managed care remains vibrant. There, managed care has pioneered the use of pay for performance, which figures prominently in the new healthcare reform law.

Beware: New Superbug Widespread in India

UK doctors: New superbug gene could spread widely

LONDON – Travellers coming back from India after medical procedures have brought back to Britain a new gene that allows any bacteria to become a superbug, and this type of drug resistance could soon appear worldwide, and scientists warned.

Though already widespread in India, the new superbug gene is being increasingly spotted in Britain and elsewhere. Experts warn a surge in antibiotic resistance due to the booming medical tourism industries in India and Pakistan, as patients import dangerous bugs to their home countries.
So far 37 people had been identified with the superbug who returned to the U.K. after undergoing surgery in India or Pakistan. The superbug gene can be swapped between different bacteria to make them resistant to most drugs.
The resistant gene has also been detected in Canada, Australia, the U.S., the Netherlands and Sweden. Since many Americans and Europeans travel to India and Pakistan for elective procedures like cosmetic surgery, it was likely the superbug gene would spread worldwide, the researchers say .
In an article published online Wednesday in the journal Lancet Infectious Diseases, doctors reported finding a new gene, called NDM-1. The gene alters bacteria, making them resistant to nearly all known antibiotics. It has been seen largely in E. coli bacteria, the most common cause of UTI , and on DNA structures that can be easily copied and passed onto other types of bacteria.
The researchers said the superbug gene appeared to be already circulating widely in India, where the health system is much less likely to identify its presence or have adequate antibiotics to treat patients.

the new superbug emerges 
 
"The potential of NDM-1 to be a worldwide public health problem is great, and coordinated international surveillance is needed," the authors wrote.
The numbers of people who have been identified with the superbug gene remains very small, though.
"We are potentially at the beginning of another wave of antibiotic resistance, though we still have the power to stop it," said Christopher Thomas, a professor of molecular genetics at the University of Birmingham who was not linked to the study. Thomas said better surveillance and infection control procedures might halt the gene's spread.
Thomas said while people checking into British hospitals were unlikely to encounter the superbug gene, they should remain vigilant about standard hygiene measures like properly washing their hands.
"The spread of these multi-resistant bacteria merits very close monitoring," wrote Johann Pitout of the University of Calgary, Canada, division of microbiology, in an accompanying Lancet commentary.
International surveillance of the bacteria, particularly in countries that actively promote medical tourism, Pitout emphasized.
" If family doctors have to treat infections caused by these multi-resistant bacteria on a daily basis, the consequences will be serious" he wrote.

Khazanah Malaysia beat Fortis India for Parkway Singapore ownership

Malaysia's Proton Car in Geneva

What next for Fortis after it loses bidding war for Parkway?

India’s Fortis Healthcare has lost out to Malaysian government company Khazanah in the bidding war for Singapore based Parkway Holdings. Fortis’s main Indian rival Apollo Hospitals has links with Khazanah and expects to benefit from new joint ventures. The key to understanding why several parties were so interested in Parkway is that Apollo, Fortis, Parkway and Khazanah see many opportunities not only in their own countries, but across Asia and beyond. The simplistic version is that all see massive opportunities in attracting medical tourists to their hospitals. On this, they compete with countries and hospitals worldwide. Many of their competitors are happy to slowly expand in their home countries and attract domestic and medical tourist customers.

These four companies, although different in approach, size and management style, have a longer term and wider vision. They understand that there is a finite limit to how many people they can persuade to go to another country for surgery or a health check. They also understand that modern private healthcare is increasingly global. So their aim, on their own and with private and public partners, is to build new hospitals in countries where people will want treatment, but in their own country. Asia, and particularly China, is seen as offering huge potential, but other countries are under the microscope too. The trick is getting into a new country or area, ahead of local and international rivals.

Fortis saw Parkway as a vehicle for international expansion, particularly into South-East Asia. Fortis Healthcare will sell the 24% stake it currently holds in the Singapore’s largest hospital chain to Malaysia’s sovereign wealth fund Khazanah Nasional Berhad. So instead of borrowing money to buy Parkway, it will get money from exiting Parkway. Fortis can either try to increase its investments at home or look for other targets similar to the Parkway chain. Malvinder Mohan Singh of Fortis says, “We intend building a pan-Asian and global healthcare group and will explore other organic and inorganic opportunities within the region. Our vision for a global healthcare service provider which can cross leverage learnings across geographies, optimize cost and provide the best quality to the benefit of the patient has not changed. We hope to re-invest the value unlocked from this experience to support our vision to become a global healthcare provider.”

The acquisition of Parkway would have turned Fortis into Asia’s largest private healthcare network, with a presence in Bangladesh, Brunei, Cambodia, China, India, Indonesia, Malaysia, Mongolia, Myanmar, Pakistan, the Philippines, Russia, Saudi Arabia, Sri Lanka, Ukraine, the United Arab Emirates and Vietnam. Now Fortis will have to find other ways to expand. Fortis had hoped to use Parkway’s brand and secure a pan-Asia recognition that would help it promote medical tourism.

Demand for private medical services has been growing in Asia as incomes rise. Most of Asia’s medical tourism is intra-regional, or from the Middle East and Africa, with a flow of patients from countries with less developed healthcare infrastructure towards those with better hospitals, rather than the widely promoted opportunities for Americans and Europeans to get lower cost healthcare. Singapore was an early mover in medical tourism. Parkway has shown that middle class patients from developing countries such as Indonesia can be tempted to make the short flight to Singapore for a standard of healthcare that is difficult or impossible to obtain in their own countries.

Parkway runs three hospitals in Singapore, with a fourth under development, plus one in energy-rich Brunei, six in China and two in India. In addition, it runs 11 in Malaysia, including nine operated by the Pantai group, in which it has a 40 per cent stake, with Khazanah holding the remaining 60 per cent. The Malaysian government has identified private healthcare as a key sector for development, and recently announced a series of initiatives to promote the industry, including tax breaks for new hospitals aimed at medical tourists, simplified visa requirements for patients and incentives for medical specialists to work in the country. Khazanah has not revealed plans for Parkway, but unlike Fortis it does not run hospitals, it will probably just act as a source for funding new investments and may encourage Parkway to look for partners in joint deals, to give it the expertise in countries where it does not operate now.

Where does Apollo Hospitals fit? Khazanah has a stake in Apollo and Apollo has partnerships with Parkway. Apollo plans to build 100,000 beds per year for the next two decades. It has 50 hospitals in India and other countries. Apollo Hospitals owns, part owns or manages hospitals in Mauritius, Ghana, Nigeria, Yemen, Bangladesh, Kuwait, Seychelles, Sri Lanka, Caribbean islands and the Dutch Antilles. It has just agreed to manage the Indira Gandhi Memorial Hospital located in Male, Republic of Maldives. Apollo is also developing business by technical innovation. It is now offering endovascular treatment [liberation treatment] to patients with multiple sclerosis and has already performed this procedure on 35 patients from Canada and the USA. India’s oldest corporate hospital chain attracted 60,000 foreign patients in 2009.

India's booming surrogate mother industry: New Regulation

slums of Mumbai







The Slumdog Surrogate Mothers

Until recently, the 350 clinics offering surrogate mother services to the hundreds of medical tourists coming to India every week have been unregulated. But legal cases in India and other countries, mean that this profitable free-for-all will be replaced by regulated agencies being forced to comply with national and international law.

India's Supreme Court has demanded urgent new legislation to regulate one of India's fastest-growing industries. India has become the world capital of outsourced pregnancies, where surrogates are implanted with foreign embryos and paid to carry the resultant babies to term. In 2002, the country legalized commercial surrogacy in an effort to promote medical tourism. Indian surrogate mothers are readily available and cheap. A draft bill to direct assisted reproductive technology (ART) will be introduced this year in Parliament. The new legislation will make law the surrogacy guidelines of the Indian Council of Medical Research (ICMR) that are often ignored by Indian fertility clinics.

Many of the couples using India are from countries where surrogacy is either illegal or unaffordable. Surrogacy costs $12,000 to $20,000 per birth in India, compared to $70,000 to $100,000 in the USA. Most surrogate mothers are rural women in need of income. Indian surrogates are usually paid between $5,000 to $7,000 for their services, which is more than many of them would be able to earn after years of work. In some Indian clinics surrogates are recruited from rural villages, with most recruits being poor and illiterate. Surrogacy recruits are brought to the clinics where they are required to stay in the clinic’s living quarters in a guarded dormitory-like setting for the entire pregnancy.

There have been several cases in which babies born from Indian surrogacy arrangements were stateless, in which neither India nor the parents’ home countries recognized the babies’ citizenship. Japan considers the woman who gives birth to a baby, the surrogate, to be the baby’s mother. Until recently, two-year-old twin toddlers were stateless and stranded in India. Their parents are German nationals, but the woman to whom the babies were born is an Indian surrogate. The boys were refused German passports because the country does not recognize surrogacy as a legitimate means of parenthood. And India does not confer citizenship on surrogate-born children conceived by foreigners. Only after a long legal battle did Germany allow the boys German passports.

The new proposed government bill bans in-vitro fertilization (IVF) clinics from brokering surrogacy transactions. It also calls for the establishment of an ART bank that will be responsible for locating surrogate mothers, as well as reproductive donors. Fertility clinics will only come into contact with surrogates on the operating table. Clinics see this as unworkable as they want to perform medical and background checks. But the new rules seek to protect surrogate mothers with freedom in negotiating their fee and mandatory health insurance from the couple or single employing them. Firm legal standards will ensure that medical professionals only be permitted to implant three embryos in a woman's uterus per attempt. The legislation will only allow a woman to act as a surrogate up to five times, less if she has her own children, and will impose a 35-year age limit. The new legislation will require that the international couple's home country guarantee the unborn infant citizenship before a surrogacy can begin. If this stipulation becomes law it could kill the industry as few countries will or legally could guarantee citizenship before birth. Countries accepting surrogate-born children typically rely on DNA tests done post-delivery to determine the parentage of the baby.

Transform your healthcare facility into a medical tourism destination

Dr. Chan Kok Ewe, of the Penang Health Association Malaysia, gave a speech at Glow 2010 in Kuala Lumpur recently. He made some interesting points-

One of the biggest challenges for healthcare professionals striving to expand their current business and market share is to reach out to new potential patients and customers. With faster, easier and cheaper communications, a treatment in another country does not seem so frightening to patients anymore.
The medical tourism and global healthcare trend has opened many doors for owners and managers of hospitals and clinics all over the world. But how do you actually turn your healthcare facility into a global destination?
Medical tourism and health tourism often get mixed up, even though there is a clear difference. Medical tourists travel to another country for medical treatment, while health tourists are more concerned with their general health and well-being.

So, what are the distinctive factors that all medical and healthcare facilities must achieve to be competitive on the global market?

Service factors
• Facilities must be more comprehensive. The patient care and equipment must be better than what the international patients could find at home.
• Better outcomes of treatment. The patient must be reassured that the result will be better than anticipated for the same treatment at home.
• Shorter waiting times. Treatments for urgent procedures must be available very fast
• Attractive comparative prices. The treatment, service and stay must be cost effective.
• Comfort of cultural and language factors
• Minimal personal adjustment. The hospital should adjust to the patient. The patient must not have to adjust too much as it might influence the healing process.
• Offer an almost like home environment.
• Easy setting for accompanying persons. The patients’ family or friends that come along for assistance and comfort should be able to stay with the patient during the visit.

Infrastructure convenience
• Ease of entry, stay and exit. It should be easy for the patient to get to and from the facility, as well as the country of care.
• Communication facilities to reach expectations .The means of pre and post communication with the patient must work well.
• Safe and clean environment.
• Simple payment. It should be easy and fast for the patient to make payments for their treatment.

Ready accessibility
• Direct convenient rapid access. The patient must be able to get to the facility fast and easily.
• Assistance in getting to treatment. Both airport collect and delivery, and transport to and from and within the facility each day.

Realistic targeting of potential
• Current and future economic development of target markets. Carefully investigate your target market.
• Keep an advantage.
• Ability to cater to demands. With the raised level of quality, patients will also have greater demands that need to be met or surpassed.
• Political alignment is not out.

Getting the buy-in
• In-country presence .The healthcare facilities must have an agent or office in the country that they cater to.
• Sharing of know-how in related areas.
• Cultivation of goodwill.

Total patient satisfaction
• Continual quality service upgrade.
• Language proficiency. The healthcare facility must speak the patient’s language to bridge any potential gaps in communication and understanding.
• Appropriate cultural responses through acquaintance. The healthcare provider must do its best to understand the patient’s culture.

According to Dr. Chan Kok Ewe, the effect of the economic downturn has hit all medical tourism markets during the last few years and growth is expected to be less than in many predictions. But this must not affect the service. Efficiency is always required, and there can be no compromise in patient safety. Instead, healthcare providers should use the time now to develop services, medical and other quality, or they will not benefit from future growth.

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Redefining the globalisation of healthcare

Here is the expectations:
More than half of US citizens are uninsured or underinsured and therefore they can not afford the very expensive US Healthcare facilities and therefore they need to seek healthcare providers abroad and therefore they will come to your countries in drove since your countries are much cheaper blah blah hubba hubba etc etc. And since we are talking about the US of A here we obviously need their accreditation so their citizen will be attracted to our hospitals.

Wake up people!

Zahid Hamid of medical tourism facilitators, Euromedical Tours, doubts whether global healthcare will ever become a reality. He considers the realities of patient mobility and suggests that successful healthcare providers and medical tourism businesses will focus on their regional catchment area and the untapped potential for medical travel.

Attracted by optimistic projections of the uptake of healthcare travel, and the mother lode of fifty million uninsured and underinsured Americans, every country, service provider and hospital seems to have entered the medical tourism fray.

With the advent of US healthcare reform, the optimism has been renewed by some protagonists. A saner view holds that there will be no immediate impact of the reform and it is only after 2014 that one may begin to determine the impact of the US legislation.

If the healthcare travel industry is to rise to the challenge of serving patient mobility effectively, it must first understand the dynamics of the industry. The industry is not in its nascent stages any longer to be lured by projections based on a wing and a prayer. There is sufficient empirical data to make more accurate predictions that serve the industry rather than telling the commissioners of the research what they would like to hear. There is only so much one can do to ‘push’, let’s also get to grips with the ‘pull’ factor to understand the dynamics completely.


The pattern of patient mobility in medical tourism

Let us examine patient mobility to destinations that have emerged or are staking a claim to being centres of excellence. An unmistakeable pattern emerges;

a. Malaysia gets 65% of its healthcare visitors from Indonesia.

b. Thailand attracts 80% of its medical tourists from South East Asia.

c. Despite its visa policy towards its neighbours, 85% of the international patients in India’s hospitals come from countries like Afghanistan, Bangladesh, Bhutan, Myanmar, Nepal, Pakistan, Sri Lanka and from non-resident Indians.

d. Jordan plays host to Sudanese and Libyan patients more than from anywhere else.

e. Turkey has drawn more patients from the nearby Central Asian Republics than the US market that it is pursuing with determination.

f. Belgium, the Czech Republic, Hungary and Poland in the European Union have seen more patients come from the United Kingdom, Germany and Italy but predominantly for treatments that fall outside the scope of insurance or NHS cover (in the case of Britain).

g. Most of the universally sought after under-insured and uninsured in America have found their way to Argentina, Brazil, Costa Rica, Guatemala, Mexico, and other Latin American destinations that are geographically and culturally contiguous. Only a very small number of patients get as far as the Far East, South Asia or West Asia.

In the case of Malaysia, Thailand, India, Jordan and Turkey patients travel from countries where facilities for healthcare are inadequate and it is convenient to seek treatment close by to contain travel costs. It also means that there is minimal cultural, linguistic and dietary dislocation.

Britons travel to European countries for cosmetic surgery or dental treatment rather than for elective procedures. Europe is culturally similar, most European destinations are between 1-2 hours away and, alive to the growing tourism needs, most people that these healthcare travellers come in contact with in these countries speak English. The experience makes for convenience and comfort that some other competing destinations not too far away – like Turkey or Jordan –find it hard to rival.

The oft repeated mantra about Britons resorting to healthcare travel because of long waiting times in an underperforming NHS does not ring true any longer. Yes, there are Britons who spend up to six months a year in Goa or Kerala, but they will not account for the windfall of patients that some projections have been based upon. Whatever its shortcomings, the NHS provides for the needs of the 56 million people dependent on it with little reason for anyone to look elsewhere for timely access to healthcare. In addition, there is the EU Directive on Cross Border Healthcare, which seeks to offer extended choice and absorb the flow of elective treatment between countries. It is unlikely that European tourist will venture beyond the Continent in search of healthcare in any great numbers.

No sooner does one land at New York’s JFK airport than the English-Spanish multilingual signs catch one’s eye. There is a natural affinity for Americans to head South to countries which abound in healthcare choices. The number of Americans who go to destinations in Latin America because it is within their ‘comfort zone’ makes these destinations a natural choice. These destinations are barely 3-5 hours away, offer ease of communication in Spanish or English languages and are culturally not too daunting a prospect for the American healthcare traveller.


Improve your understanding of your catchment area

Centres of excellence in healthcare need to define their objectives through a better understanding of the catchment areas where their target audiences reside. Only then will they be able to reorient their strategy to reach out and secure a meaningful market share. The universal quest for the elusive underinsured and uninsured American must give way to a real analysis of the pull factor that will render these hospitals sustainable and commercially viable.

The members of ASEAN (Association of South East Asian Nations) are a grouping with healthcare destinations in Thailand, Malaysia, and Singapore as well as further afield in South Korea. Other member nations have a barely adequate healthcare infrastructure and an audience that is ready to converge on to these centres of excellence in large numbers. In 2009, 49.6% of all tourists in the ASEAN region were from member nations. Japan and Australia had some 5% each and the European Union as many as 11%. These tourism streams are the funnels to target in order to maximise the opportunity in healthcare travel.

India has a middle class (per capita income of over US$ 25,000) that equals the population of the United States at around 250 million. This affluent native audience should be the target market for intra bound healthcare travel to Indian Hospitals. There should be a focus on introducing private medical insurance to fill the void in public healthcare and deliver these clients to Indian hospitals. India would also do well to begin catering to the needs of the hundreds of millions in the SAARC (South Asian Association for Regional Cooperation) countries that it borders by putting in place a mechanism that facilitates and welcomes these regional patients beyond the small stream that presently feeds its hospitals. As for the Western medical traveller, let these be a bonus.

Countries in the GCC (Gulf Cooperation Council) have a total population of under 47 million. Together with neighbouring Jordan (4.6 million) Syria (21.9 million) and Egypt (77.4 million), they constitute a region that has just enough numbers to make a healthcare system self-sustainable. Linguistic and cultural affinity and the fact that there are streams of patient traffic from Sudan (42.7 million) and Libya (6.4 million) make for a viable regional model for tertiary care across borders. There are vast tracts of land and a communications infrastructure that limits choices. If there is one place where healthcare cluster formation would help serve a sizeable population, it is here in West Asia and parts of Africa. The term “healthcare cluster” is used here as referring to a number of countries as stake holders of a single healthcare system.

Turkey is at the cross roads of the Europe and West Asia on the one hand and between Africa and Central Asia on the other. It has been a tourism destination for a variety of reasons. A developed country, with a steady flow of over 30 million tourists from various regions, Turkey must capitalise on this market share for cross fertilisation of the healthcare opportunity to an existing clientele. A deliberate effort has seen Turkey build state of the art hospitals across the country with the intention of catering to an audience beyond its 72.5 million people. The Central Asian States are a further catchment area for the developed healthcare infrastructure in Turkey in view of the location, a common cultural continuum and accessibility. Turkey must also keep itself abreast of developments in Cross Border Healthcare in the European Union as it aligns itself to seek entry into the EU. In the meantime, it must attempt to secure the client base among the European tourists that frequent its shores.

With its Directive on Cross Border Healthcare, the European Union has come a long way since Yvonne Watts’ name become synonymous with the opening up of avenues of healthcare provisioning within the EU. However, there may yet be a tortuous path to implementation of the EU Directive. Meanwhile, healthcare travel for treatments not covered by insurance is thriving in the EU. Led by service providers, clinics and surgeons, dental treatment, cosmetic surgery and bariatric surgery are available at significant savings in countries that are new entrants to the EU and account for a considerable flow of intra-EU patient traffic. Of the 70,000 UK healthcare travellers in 2006 and 50,000 in 2008, 70% went overseas for dental and cosmetic treatments and a majority of them to destinations within the EU. This private sector initiative may evolve to be the guiding light in helping the EU Directive find its feet or remain the sole manifestation of it! Destinations further afield may be excluded by provisions in policy, as in the case of the UK, for instance, where patients proceeding to a distance greater than three hours flying time may disqualify themselves from reimbursement.

Latin America has been home to the North American healthcare traveller with purpose built facilities to cater for the American healthcare traveller. Geographic contiguity, an enhanced comfort zone and an insurance mechanism that excludes a fifth of the American population means that they travel to the next best place. That, more often than not, is the short flight away in a Latin American destination. Let us not forget that the US has a litigious culture which has contributed to the high costs of healthcare. If service providers now look towards insurers and employers to come aboard, their considerations must stand the test of overcoming negligence in packaging private medical insurance for treatment in a third country. Quality and cost may add up, but can distances be overcome and continuity of care provided? The answer is yes, if the distances are manageable; this points once again to American healthcare needs being met closer to home rather than in far flung destinations across the world. Let us not forget, one compensation award for treatment gone wrong will throw the entire proposition out off the window.

It is time for the latitudes and longitudes in global healthcare to be defined. The sooner the regional context of globalisation is taken cognisance of, the better served will be patient mobility around the world; with greater patient focus, outreach and a genuine continuum of care. Will the service providers and other stake holders help themselves correct the perspective? Only time will tell.


Profile of the author
Zahid Hamid

Zahid Hamid is a Management Consultant with over thirty years of experience in the public and private sectors. He managed two software houses listed on the London Stock Exchange until committing himself to the healthcare sector in 2004. He presently heads an outbound facilitation service to Europe and South Asia – www.euromedicaltours.com - and an inbound and intra bound service to the UK – www.rightchoiceuk.com. He is a regular speaker on issues of topical import at healthcare travel industry events

GLOBAL: What medical tourists are going abroad for

RevaHealth.com has unveiled some interesting figures on the treatments UK, Irish, US and Canadian medical tourists consider going abroad for. The data is based on enquiries for treatment not actual travel and only covers people who have used their website. Although statistically flawed, it does provide some insight into consumer intent in April 2010 and over the last 12 months.

UK patients seeking dental treatment abroad;
Patients from the UK heading abroad for their dental work are still interested primarily in the top end treatments such as veneers and dental implants, but the number one treatment enquired about in April was teeth whitening, traditionally one of the cheaper cosmetic dental treatments.

UK patients seeking treatment abroad;
Looking at what treatment areas British people are looking for when travelling abroad, the top four are dentistry, cosmetic surgery, bariatric surgery and fertility.

Irish patients seeking dental treatment in Northern Ireland;
Northern Ireland remains a very popular alternative for dental treatment for Irish patients, accounting for 26% of all Irish dental enquiries in April. Expensive treatments dominate the enquiries, with braces, teeth whitening and dental crowns leading the way.

Irish patients seeking dental treatment abroad;
The favourite treatments are veneers, teeth whitening, dental implants and braces.

Irish patients seeking treatment abroad;
Irish patients looking for treatment abroad are increasingly interested in cosmetic surgery, as well as fertility and bariatric surgery. Dentistry remains the most popular area.

USA and Canada patients seeking treatment abroad;
US and Canadian patients are mainly looking for dental treatment, although this may be due to the specialties of the site rather than a general trend. Other popular areas are cosmetic surgery, fertility and urology. Mexico remains by far the most popular destination, followed by (surprise...)the Philippines and Costa Rica.

COSTA RICA MEDICINE: The First Hotel ever to complete medical tourism training course

Miss Costa Rica Pageant

In the first course of its kind, 250 staff members of the Ramada Plaza Herradura in San Jose, Costa Rica, completed a two day training programme, “Caring for the Medical Tourist”, created and delivered in Spanish by Medical Tourism Training. The hotel staff enjoyed the mix of information, demonstrations, discussions, and questions and answers, all aimed at helping them deliver better customer service to the hotel’s medical tourism guests.

Hotels and resorts are catering to medical tourists as a way to diversify and expand their client base while increasing revenues by offering services to guests before and after they receive medical treatment. The required changes to customer care vary depending on the type of medical care guests receive. The challenges and opportunities offered by serving medical tourists require careful planning and thorough preparation. Preparing staff members is a key factor to successfully serve the needs of medical tourists.

The two-session, interactive introductory programme is based on real-world scenarios. Each session is two to two and one-half hours long and covers topics including:
• Introduction to medical tourism and medical tourists;
• Cultural awareness and cultural norms;
• Providing customer care pre-op and post-op;
• Impact of staff behavior - body language, eye contact;
• VIP customer care service for medical tourists;
• Caring for accompanying guests;
• Identifying and handling biohazardous waste;
• Wheelchair assistance;
• Recognizing serious emergencies;
• ABCs of first aid;
• What to do in an emergency;
• What to do after an emergency.

Designed to ensure measurable results, the knowledge check component to the training sessions confirms that the participants are able to identify and recall the key points. A post-training evaluation ensures that the program is meeting the needs of the organization. Following the training the trainers prepare a report containing the results of the programme evaluations as well as actionable steps for senior management to improve their medical tourism services.

The training focused on the unique demands of international health travellers and is the first completed by new company Medical Tourism Training. Medical Tourism Training’s affiliated company, healthcare consultancy firm Stackpole Associates, compiles quarterly surveys of the hotel’s current and past guests, of all kinds, to evaluate their awareness of medical tourism and to plan for improved hotel services for medical tourists. The company is developing other training programmes designed to have a broader appeal to healthcare providers, agencies and others in the medical tourism field.

Medical Tourism Training’s Elizabeth Ziemba says that healthcare providers lose customers because they are not meeting the service expectations of international health travelers, “Prompt and polite communications are essential to success in this sector that is relationship driven. Every phone call or e-mail that goes unanswered or employees that react poorly to foreign customers lose business. Our programmes train staff, instilling effective, proven skills that can transform relationships with medical tourists.”

The company is also offering "Medical Tourism Guests: The Right Choice for your Hotel or Resort?” This 90-120 minute presentation is designed for senior management teams that are expanding services for medical tourists and their accompanying guests. It addresses the planning and management issues vital to creating and tailoring services for the medical tourism market:
• Background information about medical tourism opportunities.
• Issues and challenges associated with serving medical tourists and their accompanying guests.
• Management and planning tactics including:
o Changes/additions to physical environment;
o Designing and delivering VIP customer care;
o Staff training and preparedness;
o Developing relationships with key ancillary services.

Turkey wants to double the size of its medical tourism

Bosphorous Bridge connecting Asia to Europe












Effective promotion could double potential for medical tourism

Turkey could see the size of its medical tourism market double if an effective promotion campaign is put in place, says Levent Baş of Turkish medical tourism agency Gusib,“We are expecting to see an approximate 10 percent growth this year over 2009, but with effective promotion, the year-on-year growth in the sector could even exceed 30 percent. There is a huge potential as regards the future development of medical tourism in Turkey, a country that has the world’s second highest number of hospitals with Joint Commission International (JCI) accreditation. This is a clear indicator that Turkey is home to a well-developed medical treatment infrastructure and the country offers the most affordable prices possible in comparison to rivals such as India or Thailand.”

Bas continues, “There will be a remarkable boost in the number of medical tourists to Turkey if we can manage to promote ourselves as an attractive medical treatment location. The biggest drawback is the lack of effective promotion abroad. The Ministry of Tourism could take care of this; we are not asking them for incentives or financial support. The only thing we expect from the government is that they undertake the promotional aspect. Turkey deserves to become one of only a few countries in people’s minds when it comes to medical treatment abroad. It has a well-organized medical infrastructure and the advantage of geographical proximity to the large and promising markets of the EU and the Middle East. Baş says there are four medical tourism businesses in Turkey, and while this is not enough, those who enter this business must be professionals; otherwise, the market could be adversely affected.

Gusib began in 2002 in Vienna to help people from Austria, but of Turkish origin, to benefit from lower priced high quality services in Turkey. The firm then offered the services to Austrians. Gusib now works with some of Turkey’s leading hospitals, particularly in Istanbul, bringing people over from Europe, the Balkans and Central Asia. The company is also interested in the US market, which could offer opportunities for Turkey. Gusib offers all-inclusive packages including return tickets, hotels and medical treatment.

Tourists from Europe prefer Turkey for their medical treatment because prices are low, while people from the Middle East and Central Asia primarily come for the high quality of service. Most patients come for a cosmetic, eye or dental services. There has been a particular increase in demand from Balkan countries over the past few years. The promotions offered by Turkish Airlines (THY) play an important role in attracting medical tourists to Turkey as THY offers a 25 percent discount to every patient and one person accompanying them on their visit to Turkey for medical treatment.”

Baş is working on a new project that envisages attracting for long-stay winter care, particularly from Scandinavian countries, where the governments are looking for ways to minimize expenditure on retirees,” Norway is keen to send pensioners to Turkey as the government wants to pay less for their treatment and insurance, and we have enough capacity to host these people. We anticipate building village resorts where older tourists can receive the necessary medical treatment. This is a promising new field of investment and is also critical in diversifying services.”

Difficult times: Thai red-shirts splash blood on medical tourism in Thailand

Blood bath in Bangkok









Bangkok burning










Thailand’s political crisis has been ongoing for almost two months. Some hospitals and medical tourism agencies are making the point that trouble is occurring in only a few places. Some are claiming that Bangkok is safe.

Many countries are now advising their citizens not to travel to Bangkok. Some are advising against all but essential travel to anywhere in Thailand. Some are advising against any travel to Thailand. Some have even flown their citizens, some of whom are medical tourists home.

How damaging the political troubles are to medical tourism is something local hospitals and clinics may not know for months or even years to come. Persuading insurers or employers that it is safe to send people to Thailand is not going to be easy.

Overseas governments are updating advice on a daily basis and at the time of writing-
• The State Department alerts U.S. citizens traveling to Thailand of ongoing demonstrations in Bangkok.” Due to escalating violence in central Bangkok, all U.S. citizens should avoid nonessential travel to Bangkok. Those traveling outside of Bangkok in Thailand should be aware of the possibility of disturbances elsewhere and should exercise caution and good judgment.”
• The UK’s Foreign and Commonwealth office warns there is a high threat from terrorism throughout Thailand; “ Attacks could be indiscriminate, including in places frequented by expatriates and foreign travellers. You should exercise caution at all times. We advise against all but essential travel to the whole of Thailand.”
• The Australian Department of Foreign Affairs and Trade warns, " We advise you to reconsider your need to travel to Thailand due to the recent deterioration in the security environment caused by widening political unrest and civil disorder occurring in Bangkok and other parts of the country. There is a high threat of terrorist attack in Thailand. We continue to receive reports that terrorists may be planning attacks against a range of targets, including tourist areas and other places frequented by foreigners. "
• Over 30 other governments have issued warnings against travel to Bangkok, some warning against all travel to Thailand.

The increasing violence has taken its toll on tourism, Thailand's main foreign exchange earner. Tourism accounts for 6 percent of the country's economy and has steeply declined since the protests started. Cancellations are pouring in from tourists and medical travelers. The situation is serious, and it really depends now how events will turn. The longer protests go on, the more aware will be travellers around the world about Bangkok’s situation. It will then become harder to convince them to come back. Thailand has faced many crises in the last few years and Bangkok and Thailand have always bounced back more rapidly than expected.

With concerns growing around the world, the Tourism Authority of Thailand (TAT) encourages visitors not to cancel travel plans, and merely warns travelers to be vigilant. TAT encourages passengers to travel to Thailand and has been seeking support from trade partners to discourage cancellations and encourage people to travel to Thailand, amending itineraries to avoid the city of Bangkok.

Even by the middle of April, medical tourism had begun to feel the pinch of prolonged political strife. Bangkok Dusit Medical Services (BGH), the country's largest private hospital operator, said foreign patient visits decreased by 35% compared with the same period of 2009. Phyathai Hospital saw a 15-25% decline of international patients arriving compared with last April.

The most severe impact has been from Europe and the Middle East as some appointments were cancelled and others postponed. Some countries from the Middle East instructed their citizens not to go to Thailand or even hosted charter flights to take them back home.

Accreditation of Hospitals: An overview

Library, Jawaharlal Nehru University, New Delhi


Health services in many developed countries have come under severe scrutiny in recent years. Positioned against the backdrop of globalisation, there is an intense move towards accreditation of health services. Accreditation of hospitals is a voluntary process by which an authorised agency or organisation evaluates and recognises health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes.

Accreditation can be understood as an indicator of professional achievement and quality of care. Accreditation is opposed to licensing or regulation of healthcare facilities, which is usually mandatory and state-imposed. Central to accreditation are two features: the principle of external review and the use of standards.

Accreditation is not new to the health system. The first initiative towards accreditation was taken in the United States of America as early as 1910. Over a period of time after several experiments, the Joint Commission on Accreditation of Healthcare Organisation (JCAHO), a national accreditation programme, established itself as an esteemed accreditation body by 1987. JCAHO has high standards of quality assurance and rigorous process of evaluation, which makes it a much-esteemed agency for accreditation. Health services certified by JCAHO are given ‘deemed status’.

Models of Accreditation
An accreditation body has to have a restrictive relation with the State to be effective in regulating the health system

Accreditation across the globe followed three models. The first model of assessment gives priority to standards related to available facility norms, equipment requirements, human resources and space specifications. Here, the criterion of accreditation is based on the availability of basic health facilities.

The second gives importance to quality assurance and sets standards for those institutions striving to arrive or improve quality of care, hence accreditation is based on satisfying some basic indicators of quality and involves anking based on levels of quality.

The third model is based on the ground that health systems should be accessible and acceptable to health-seekers. It gives importance to the health-seeker with an emphasis on evaluating health systems from indicators such as user-friendliness, providing information to users about the services available, setting up procedures for redressing grievances, etc. In the third model, the criterion of assessment is explicitly geared towards people-centric indicators and brings accountability of the health system to the health-seekers to the table. With each model, the criteria of accreditation changes.

The accreditation process should begin with minimum or moderate level standards and, over a period of time expand to higher, “ideal” level standards and should be achievable by local public health agencies regardless of size provided that they conduct the essential services of public health.

State and local accreditation programs should coordinate with and conform in essential ways to a national accreditation program to eliminate possible duplication and conflict. To succeed in bringing about a perceptible change in the delivery services of the health system and to go beyond mere an on-site survey and awarding certificates, any accreditation programme should address all the dimensions of healthcare.

The onset of accreditation in different countries

Canada

Accreditation has had different paths and patterns of growth in different parts of the globe. In Canada, the move towards accreditation started in 1952 with the initiative from the medical profession. Presently, the Canadian Commission on Hospital Accreditation is the sole agency to accredit hospitals and enjoys complete monopoly.

Australia

In Australia, accreditation was introduced in 1926, with the state initiative but it was only in the early seventies that the Australian Council on Hospital Standards was set up. Though the accreditation programme has not received a very extensive coverage, it assures interested groups that health professionals consider it a responsibility to monitor their standards of performance. It has with other medical colleges, developed a set of clinical outcome indicators for accreditation.

United Kingdom

In United Kingdom, there have been multiple attempts to devise and measure standards. As a result, there are many accreditation systems like the King’s Fund Organisational Audit, the Hospital Accreditation Programme, Trent Community Hospital, South Western Health Records, etc. The regional health authorities have supported some of them. Among them, The King’s Fund Organisational Audit Programme and the Hospital Accreditation Programme are significant.

China

Development of accreditation system in China, has received the Ministry of Public Health’s support since inception in developing standards of regulation in four areas of treatment, namely, prevention, healthcare reconstruction, support and participation in disease prevention and care and healthcare activities.

Latin America and Caribbean Countries

Accreditation in Latin American and the Caribbean countries have begun in the early nineties with the release of certain set of hospital standards by the Pan American Health Organisation and the Latin American Federation of Hospitals. The ministry of health of Argentina and the Argentina Society of Medical Auditing prepared the original draft of the same with inputs from other experts.

The standards have two dimensions: compulsory minimum standards and the non-compulsory standards. Compulsory minimum standards have five areas of evaluation namely the organisation of medical care, technical and support areas, building documentation, functional physical structure and installations.

Non-compulsory standards include such things as critical care, neo-natology, nuclear medicine, etc. There are levels of standards, which have to be satisfied to attain highest grade. But the first level of standard has to be met for minimum accreditation status.

India

In India, accreditation of the health services has never been a serious issue though some feeble attempts have been made to evolve a voluntary accreditation system in the late eighties and early nineties interestingly coinciding with the LPG (Liberalisation, Privatisation, and Globalisation) reforms. The attempts made by the Indian Hospital Association (IHA) at both Mumbai and Delhi is worth mentioning. Their efforts were not well received as the initiative did not involve the various stakeholders and had moved with predetermined standards of evaluation, membership fees and assessment mechanisms.

In India, the initial premises of introducing accreditation were based on the overall objective to ensure the quality of care. The Bureau of Indian Standards (BIS) had laid down standards for hospitals having 30, 100 and 250 beds. The National Institute of Health and Family Welfare (NIFHFW) had such rules laid for more than 50-bed hospitals and only for equipment. Most of the standards laid down by both BIS and NIFHFW were criticized for having an urban bias. There have been attempts in some states to institutionalize uniform standards for hospitals. In Maharashtra, the government hospitals follow the Hospital Administration Manual. The Andhra Pradesh Vaidya Vidhana Parisad has laid down standards for secondary-level hospitals in the government sector, which comes under it. Apart from this some efforts have been made by consumer bodies, groups of health professionals, hospital organisations and non-governmental organisations to evolve standards for accreditation. But what was lacking was a unity of various such attempts to monitor the functioning of hospitals in India and the stringency of compliance to established standards.

At the threshold of globalization and increasingly opening-up of the Indian health sector, attempts are being made at various quarters to draft systems of accreditation. There are certain points, which cannot be missed. What does accreditation mean for India? The answer to this question would help us to know which model can be adopted for accreditation of hospitals in India. If it follows the ranking-model based on quality of services provided, accreditation will have very little to contribute to the improvement of the overall health system in India. In contrast, the facility-survey model can be partially pertinent in putting in place the basic facilities required for providing care.

The most relevant model of accreditation for the Indian health system is the people-centric model, which would ensure the presence of 4 A’s, namely Acceptability, Accessibility, Accountability and Allocative efficiency. Ensuring the presence of the above would monitor utility of the available services and orient the health system towards performance management.

The emerging system of accreditation in India has to consider the uniformity of the standards used for the purpose, the nature of the relation of accreditation bodies with the State and the role they would play in the health sector. An accreditation body has to have a restrictive relation with the State to be effective in regulating the health system. It can have observers from the government but largely it has to be an autonomous body constituted of health professionals, experts and various stakeholders.

The nature of relationship of the accreditation bodies with the to-be accredited institutions would also determine its relevance for the health systems in India. Effective regulation and monitoring will depend on whether the relationship is evaluative, educational, consultative or inspectorial and judgmental with punitive powers.

In the backdrop of the opening-up of the Indian health system to foreign patients and the increased pressure from the insurance sector seeking grading of the hospitals, there would certainly be an exceeded emphasis on quality of hospitals and other health institutions providing health care. Under such circumstances, the role of accreditation systems may be expected to be more stringent than mere consultative.

Accreditation systems over a period of time have shifted from a single system focusing on entire hospital to a more complex pattern with specialized agencies regulating and certifying parts of several compartments of the health delivery system. The structure of the agencies and methodology adopted for evaluation and monitoring/regulation also varies. In the 1980s, the accreditation systems began to consider ways of revising standards to make them more patient-focused rather than professionally focused. In the 1990s, they have revised their standards to reflect the changing functions of hospitals, seeking to move away from departments towards patient experience of hospital systems. They have all moved towards trying to find standards, which would reflect the integration of hospital services rather than examining them in isolation. Finally, they have all begun to examine outcome measures instead of simple process standards for good practice. The context in which accreditation of health services have started in India generates fear that it may only endorse inequality rather than institutionalize quality.

The rising demand for quality care, the limited healthcare investment, the growing number of private players in healthcare and insurance sector, the opening-up of the health-sector to global patients makes the search for quality an imminent reality. But a sound system of accreditation would require to take into consideration the important performance measures that affect community health status, gives due weightage to the content and outcome of the public health agency’s community contribution than to its structure and resources, should result in the strengthening of the public health infrastructure and contribute to ongoing quality improvement. It should add value to the public health process in communities.

The costs of the accreditation process should provide no economic barriers to local public health agencies wishing to participate.

Other countries
that have accreditation system and some that is in the process of setting up one are Malaysia, Spain, France, Pakistan, South Africa, Italy, Taiwan, Netherlands, and Israel among others. Over a period of time accreditation systems have moved away from single system focusing on entire hospitals to more complex patterns.
Dr Chandrima B Chatterjee