A Letter to the Finance Minister

Dear Madam Finance Minister,

I must start by acknowledging the very difficult task that you have in front of you. Preparing the Union Budget this year, in times of such economic turmoil, is far from easy. Ordinary people of the country have huge expectations from the budget and I know, it is almost impossible to meet everyone’s aspirations. I am also sure economists and self-styled pundits of all hues must be offering you gratuitous advise on how to aim for greater growth, generate employment, rein in the burgeoning deficit and balance the budget. I am no expert in these matters and hence will refrain from adding to the chorus. My sole purpose in writing to you is to draw your attention to the healthcare sector and the urgent support it needs from the government.

As you might be aware, the National Health Policy of the Government of India itself has committed government spending on healthcare at 2.5% of our GDP. Currently, the government spends a measly 1% of the GDP on healthcare. This isn’t getting us anywhere at all. The health of the citizens of the country and their access to good quality healthcare you would accept is of paramount importance. Even a small increase in the allocation for healthcare can go a long way in improving public healthcare infrastructure particularly in the far flung regions of our country and in the area of primary healthcare.

The government had announced the world’s largest healthcare insurance scheme called Ayushman Bharat a couple of years ago. The scheme was envisaged to provide an insurance cover of INR 500000 to over 500 mn poor people. The scheme is indeed ambitious in its scope but does suffer from lack of funding. The insurance companies (mostly government owned) have been arm-twisted to accept extremely low premiums and private hospitals are being asked to support the scheme even though it is almost impossible for them to provide good quality healthcare at the government mandated price-points. Ayushman Bharat, which is designed to provide access to healthcare to the poorest of our poor needs proper funding and government support. I trust, this will be right on the top of your agenda, while looking at competing demands for funds from other government welfare schemes.

The private sector provides the bulk of healthcare to the citizens of our country. In the last couple of years the private healthcare players have had a tough time with respect to the regulatory environment mandating price capping for medical devices like stents, joints and life-saving cancer drugs. While, this has helped the common man in making healthcare more affordable, the hospitals have seen their slim margins shrink further. It would greatly help if the government was to include healthcare sector in the ambit of infrastructure sector. This will allow private sector hospitals to raise funds at low costs, which will go a long way in shoring up their sagging profits, which in turn will kick-off fresh investments in new capacity, technology and new jobs.

To attract private sector healthcare investments in smaller cities and towns in India, you must consider offering incentives and subsidies to private healthcare players. They will be able to partner with the government in setting up ”low cost” hospitals, readily accessible to most of our citizens at attractive price points. This will lead to investments and job creation, locally something that the government will be delighted with.

Healthcare insurance penetration in India is abysmally low. Most people are either uninsured or under-insured. This makes quality healthcare completely inaccessible to a very large number of our citizens. It would be very useful if the government was to consider making healthcare insurance mandatory for all private sector employees with the responsibility of providing a suitable cover with the employer. This should be mandated for all Small and Medium sector organisations as well thus dramatically increasing the number of people covered under healthcare insurance. While, we are at this, may I also point out that the Central Government Health Scheme (CGHS), which covers millions of serving and retired government employees is in dire financial straits and owes millions of dollars to private healthcare providers, who are now increasingly constrained to refuse services to CGHS beneficiaries by opting out from the CGHS panel. You must consider funding CGHS and other similar government schemes adequately so that their beneficiaries continue to receive adequate healthcare.

The export of healthcare services from India popularly called Medical Value Travel (MVT) has the potential to earn billions of dollars of foreign exchange for the country. Indian healthcare service providers have tremendous advantages. They deliver quality healthcare at very low costs. We have the potential of attracting people from all across the world to India for medical care. Last year, at Max Healthcare, where I work, saw patients from over 110 countries. The opportunity is immense. However, we do need some help from the government in marketing India as world-class destination for inexpensive healthcare. The previous government had set up a board to promote wellness and medical value travel to India. For the last few years, it is lying defunct. It would be very useful to revive this board with adequate funding, infrastructure and a clarity of vision to help promote India and its healthcare prowess across the globe. Tax breaks and incentives to private healthcare players investing in MVT will also go a long way in attracting foreign patients.

Finally, I must draw your attention to technology, which is changing the landscape of healthcare delivery across geographies. India has an excellent penetration of mobile telephony and we can deliver and address a lot of healthcare concerns of our citizens using technology. A mobile phone can be used to capture healthcare data remotely, images can be sent and analysed, AI applications can be used to report and diagnose smartly. The world is increasingly moving in this direction. My request to you would be to set aside a small sum of money and create a mechanism, which encourages entrepreneurs to invest in these technologies helping deliver healthcare to our people living in far-flung areas of the country with limited access to healthcare.

Madam, the health of its citizens has to be a major priority for any forward looking government. I am sure, you will be addressing some of these concerns in you budget proposals. We are eagerly waiting to hear from you.

The views expressed are personal

Medical Value Travel in India-A promise yet to be fulfilled.

For at least the last 10 years one has been hearing about the Medical Value Travel (MVT) market in India touching a whooping USD 5bn, 8bn or even 10 bn by 2020. These are breath-taking estimates provided by venerable consulting firms from almost 10 years ago. These had been quoted ad-nauseum by all manner of people (including, I must confess, myself) as the potential of MVT in India in presentations made to likely investors, foreign governments and indeed overseas hospitals with the potential to send patients to India. Many analysts have cited it as the next big thing after India’s dominance in exporting software to all parts of the world. It has been touted as the real big thing about to hit our shores.

Sadly, the reality has turned out to be a little different. The big wave hasn’t really reached our shores. The MVT business including those flowing into sectors like travel and hospitality would today be well under USD 2 Bn.

So, what worked and what didn’t and more importantly what needs to be done?

In my view what has largely worked for MVT in India has been the outstanding medical services and world class outcomes that our clinical teams continue to generate. The commitment of the clinicians, private investments in additional beds, equipment and technology has helped deliver cutting-edge care to thousands of patients who continue to travel to India in search of better health. Increased competition among private hospitals have also ensured that pricing hasn’t gone through the roof and India still is by far the least expensive destination for high-end medical care.

Medical outcomes and care are just one part of what patients look for when they wish to travel abroad for healthcare. Sadly, we have not done as well in almost everything else.

The government of India is still not very friendly towards medical travelers. In many countries the Indian missions have archaic rules for issuing medical visas, often the patients themselves have to spend time in long queues outside the embassies to apply for visas and touts merrily ply their trade. The International airports even in major Indian cities do not have adequate facilities to receive sick patients. While, immigration counters for people traveling on medical visas have come up, a lot more can be done at the airports to ensure greater comfort for weary travelers who are also sick, often seriously.

Even those private hospitals in India who are teeming with thousands of international patients have very scratchy patient services. Almost every aspect of non-medical services is neglected. The interpreters are few and of dubious quality, patient concierge services do not exist and hardly any hospital makes the effort to serve the patient’s preferred cuisine. Information regarding the treatment plan, medical risks involved, and prognosis is usually scarce, and patients must depend on unreliable sources such as clinician’s secretary and other assistants to get whatever information they can get.

The biggest bugbear of all remains the unreliability of patient estimates. Healthcare is an inexact science, it is almost impossible to predict with great accuracy the course a patient may take in a hospital. However, hospitals wishing to treat international patients must come up with fixed price packages for at least the most commonly done procedures and surgeries and ensure that the bills of foreign patients do not escalate.

To make matters infinitely worse, often the patients are assisted by the so-called Healthcare Facilitators (HCF’s) who are still largely individuals (and not well organised institutional service providers) looking after ”their” patients. Most of them have the right intention to assist the patients during their stay in India, however they are seriously hampered by a lack of organised resources and well-established processes. Sadly, some are plain opportunists, who dump patients in hospitals, which pay the maximum commissions and disappear thereafter. There is a crying need and a great opportunity for medical concierge services providers to set shop and look after foreign patients in need of assistance. The established hospitals must also encourage and support the emerging organised players in this space.

MVT in India (also healthcare in general) remains unregulated. It is extremely important that the government urgently creates an independent regulatory body, which works closely with MVT stake-holders to set up rules for all those involved in medical value travel. These will include airlines, hospitals, hotels, spas, ayurveda centres and HCFs. Quality standards need to be developed and implemented in all the aspects of MVT. Accreditation norms must be a lot more stringent and command greater respect.

The other big problem that remains unaddressed is the sheer lack of information and knowledge about modern India and its medical capabilities. Most people abroad have preset notions of India being largely an over-crowded nation of over a billion people mostly mired in crushing poverty and squalor. This is clearly a uni-dimensional and dated narrative completely at variance with reality. All stake holders in MVT in India including the government and private healthcare providers must join hands to work towards dispelling this notion about India. A campaign like ‘’Incredible India’’ is sorely needed.

Essentially, MVT in India has not done as well as expected because of a lack of vision on the part of key stakeholders namely the private hospitals, the government and the HCF’s. All three need to seriously introspect. The hospitals and the HCFs need to look beyond just the next patient and invest in better infrastructure, better systems and processes, better quality people and a greater commitment to overseas patients. The government needs to create a regulatory and supportive environment, which allows them to function well and with greater efficiency.

This can’t be too difficult.

All it requires is greater alignment, focus and commitment among all MVT stakeholders.

The views expressed are personal

Resisting the advance of Medical Value Travel is Futile

As I travel to various parts of the world promoting Medical Value Travel (MVT) to India and Max Hospitals, in New Delhi, I am increasing becoming aware of a certain kind of resistance bordering on hostility in different quarters. The last time I was in Kenya I happened to meet a local parliamentarian in Nairobi. The parliamentarian articulated this phenomenon rather well. As per his world view MVT entails a significant leakage of foreign exchange from impoverished sub-Saharan African nations to wealthier nations with fancier (and not necessarily better) healthcare systems. He felt that hospitals chains from India and Thailand and elsewhere tend to ”lure” away gullible patients to their shores even though the patients can be treated locally as well. The MP was of the view that only those patients should be allowed to travel abroad, who cannot be treated in Kenya itself.

Sadly, a similar view is also being articulated by many local clinicians as well as various Medical Associations and regulatory bodies in several parts of the world. They are making it difficult for foreign clinicians to come and work in their countries by raising inappropriate barriers such as the requirements of multiple licenses and permissions from sundry agencies. Essentially, behind all this lies fundamental insecurities and an almost cavalier disregard for what might be the best for the patient.

People travel far away from their homes in search of quality medical care for three main reasons.

  1. The Services are not locally available or are scarce.
  2. The services are available but are too expensive.
  3. The services are available but are not easily accessible to patients.

Unless a nation addresses these issues, MVT is unlikely to go away.

By being mean spirited and denying foreign doctors and hospitals to collaborate with local medical establishments is clearly foolhardy. International medical collaboration leads to exchange of knowledge and transfer of skills. That is usually the quickest way to upgrade local expertise and instill confidence in local clinicians to take up difficult cases initially under the guidance of foreign experts and later, on their own. There is nothing shameful in learning from someone who has greater knowledge or expertise.

Moreover, such practices are against the best interests of the patients, which all doctors are under oath to protect. ”As a father of a sick child with a congenital heart problem, why should I be denied the opportunity of seeing a foreign expert if he is willing to travel and visit me in Nairobi? Why should I not have the opportunity to take his opinion and compare it with what is available locally and decide for myself, what might be the best for my son?” asked John Kutolo, whom I met in Nairobi in October 2018.

The argument that people should not be allowed to travel abroad if the clinical service is available locally is quite disingenuous. The availability of service is just one aspect of the decision to travel abroad for treatment. The big question really is the quality of the service available and more importantly the trust that one has in the local medical services. Thus, it is possible that Kidney Transplants may be happening in Nigeria, however if I, as a patient or a care-giver do not trust the local hospital, why should I be forced to get my transplant done there?

Often people travel abroad for treatment because healthcare costs in many countries are humongous and insurance coverage either non-existent or severely limited. If the patients and the care-givers have confidence in their decision of traveling abroad, where they can possibly afford good quality healthcare, they should certainly have no difficulties in accessing such services. Similarly, if one chooses to get treatment done at low costs in a foreign country rather than wait for months in some places like Canada, UK or Russia, they should be able to do so unhindered. False pride in one’s country’s medical systems should not come in the way of offering foreign treatment options to patients who can than decide what might be the best for them.

While, I do realize that most hospitals sending their doctors and medical teams to war ravaged countries like Iraq or under-developed nations like those in the Sub-Saharan Africa clearly have a profit motive in encouraging patients to travel, the fact is that patients travel only when their clinical needs are not satisfactorily met locally. No one really wants to be thousands of miles away from family and loved ones during a risky medical procedures.

Finally, it all boils down to a patient exercising a choice over who and where she gets treated. I believe that the patients should have complete access to information regarding all relevant options and they should be free to choose. If this means that they should get to interact with visiting clinical teams from foreign lands, than they must be able to do so without hindrance.

The only way to counter MVT is for the governments and private enterprises to invest in healthcare infrastructure, build world-class, technology led institutions and have a steady supply of trained and experienced clinicians. All this must also be easily accessible to most citizens and at competitive prices.

Unless that happens, MVT is here to stay.

The views expressed here are personal