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.

Still Think You Need JCI Accreditation?

i am a tiger...










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