Why hasn’t India’s medical tourism boom boosted local hospital infrastructure?

Beyond the success story of India's burgeoning medical tourism, what are the critical challenges plaguing the nation's healthcare system?

In recent years, India has emerged as a leading hub for medical and wellness tourism, especially in areas like orthopaedics, oncology, and robotic surgery. Despite the challenges posed by the COVID-19 pandemic, India attracted approximately 650,000 medical tourists in 2022, as per reports from the Federation of Indian Chambers of Commerce & Industry (FICCI). After briefly slowing down due to the pandemic, medical tourism in India bounced back with nearly double the footfalls in foreign tourist arrivals (FTA) for medical reasons. 

Currently, Indian medical tourism accounts for a staggering 6.5 per cent of the global tourism market. People seeking medical aid from around the world travel to the country for its cutting-edge private healthcare infrastructure, well-trained experts, and high-quality treatments. Yet, the main allure of India's medical tourism sector lies in its cost-effectiveness.

Doing away with stringent formalities

Lavanya Narayanan, a food and culture writer based in the United States, prioritises dental procedures when seeking medical care in India. “One of the things that’s pretty costly even with healthcare in the US is dental treatments. The medical insurance will only cover a fragment of the total cost incurred. So I prefer doing any dental work–crowns or root canals–in India.” 

Here, Narayanan pays about 20 to 25 per cent of the cost of dental procedures in the US. She has also been taking medical scalp treatments, each session costing her ₹ 2,000 (approximately US$25). 

Even for colonoscopy or HIDA scan (hepatobiliary iminodiacetic acid scan—a test to diagnose liver and gallbladder conditions), the insurance coverage in the US can be limited. “For such medical procedures, a doctor needs to submit a detailed report citing reasons for undergoing that particular procedure, their diagnosis and treatment. The insurance authorities have every right to deny your claim, and here, without insurance, medical care can get very difficult,” says Narayanan.

Unlike in the US, a less formalised setup in India essentially means a patient does not need pre-authorisation from the doctor for such procedures. The informality extends to other aspects of healthcare as well. “It’s interesting that you can directly communicate with doctors over calls or WhatsApp, especially if they are running personal clinics. That is pretty rare in the US. You usually have to message on a portal through a hospital network,” says Narayanan.

Accounting for costs

Pierre Cornet aka Frenchy, a French travel vlogger who has extensively travelled across India, including Ladakh, West Bengal, Himachal and Kashmir, emphasised that he was “impressed” with the care he received during a throat surgery he underwent at Alchemist Hospital in Panchkula, Chandigarh. He had undergone a surgery to remove a benign tumour from his throat, and paid around US$500 (₹ 41,000) for the entire procedure. 

However, his experience was “very different” in Kashmir, at a government hospital he visited after testing positive for COVID-19. 

“At the time, I was in Aru Valley, a remote part of Kashmir, where there was only one clinic—in a government hospital. I didn't have to spend a dollar for my consultation, and only a few dollars for medicine, but what I remember is that the hospital was extremely crowded, and during my consultation, I found it quite challenging to focus because of the constant influx of other patients bombarding the doctor with questions. Which is why I would prefer to go to a private hospital as they have better equipment and infrastructure,” he remarks. 

A widening doctor-patient gap

Like Frenchy, regardless of one’s financial capability, individuals have turned to private healthcare even for minor ailments such as colds, fevers, and diarrhoea, specifically in urban centres. While India is already one of the leading destinations for foreign patients seeking care, a very large section of the country still struggles to access basic healthcare. It’s a curious predicament, considering there has been a statistical increase in government expenditures to alleviate the individual burden of medical expenses in recent years. In West Bengal, for example, all kinds of treatment, from diagnostic to surgeries, OT charges and beds are provided free of cost at government-run facilities. According to data obtained from the National Sample Survey 2017-18, only one-third of our population goes to public healthcare facilities for any of their medical requirements. 

For one, government hospitals are dangerously short-staffed. 

Dr Amit Ghosh (name changed), a medical professional associated with the paediatric department of a state hospital in Kolkata, describes the doctor-patient ratio as “frightening.” But the even bigger concern, he notes, is the ever-widening gap between the number of nurses required and the number of nurses present.

The scarcity of doctors, nurses, and even paramedics has compelled physicians to bear additional responsibilities. “On instances, I have had to set up the X-ray machine all by myself because there was no paramedical staff available, especially for night shifts. Even in the mornings, they are usually so overworked that they would miss coming to our ward at times, but for no fault of theirs.”

There is also a dearth of trained personnel to cater to ambulance services. “Too many patients decompensate or die en route from the peripheries to the centre. If there were more trained paramedical staff for ambulances, patient death could dramatically be reduced,” asserts Ghosh. 

In rural areas, the gap between the number of medical professionals and patients is even wider. “On any given day, our outpatient department (OPD) handles approximately 500-600 patients. Beyond doctors too, you need staff for crowd management. There is no one to queue the patients up in a systematic order. At best, a doctor can only devote a minute or two per patient. But this poses a considerable risk, as it increases the likelihood of misdiagnosis,” warns Dr Binay Paul, (name changed), senior resident at the ENT department of a West Bengal government facility. 

On the other hand, some experts argue the shortage of doctors in rural areas is not primarily due to insufficient supply; many doctors choose not to practise in rural regions for multiple reasons, including worries about basing their family at a place with scant opportunities, limited professional connections, and feelings of isolation.

A lack of qualified specialists? 

General practitioners or GPs alleviate the strain on the healthcare system by lowering the demand for hospitalisation or specialised treatment. In rural areas, general physicians often stand out as the most qualified practitioners to deliver efficient healthcare. However, of late, more and more doctors are moving towards specialised fields from a young age, in a bid to secure better job opportunities. The anxiety of securing well-paying jobs, coupled with the competition for the 25,000 post-graduate seats makes students focus on a more theoretical, specialised approach towards medicine than the broader focus of general practice. 

“It seems that the [MBBS] degree itself may have depreciated in value in our collective consciousness. So just an MBBS degree is no longer as desirable as it once was. Everyone is worried they won’t get well-paying jobs if they do not begin planning early,” says Paul. 

This, in turn, has led to professionals not knowing the ropes of practical training. In peripheral practices, there is a noticeable absence of nurses or paramedical staff. Consequently, doctors are required to possess skills such as setting up intravenous lines or administering a nasogastric tube. “On many occasions, younger doctors are not too well-versed with these procedures, which becomes a major cause of concern,” emphasises Paul. 

Where there is a dearth of general practitioners in rural regions, a significant 68 per cent of specialist positions presently remain vacant, according to data obtained from the Ministry of Health. These specialists demand sophisticated medical infrastructure, a luxury often absent in rural settings. Because of the limited supply of doctors, rural healthcare is heavily dependent on “quacks,” points out Dr Abheek Sil, a senior resident at Kalimpong District Hospital. 

“Over the years, the accessibility of affordable healthcare has been a major achievement. But unfortunately, the chunk of healthcare providers in rural areas are nothing but quacks. The next step should be to focus on quality. Emphasis should be on promoting qualified professionals and not self-marketed social media gimmicks,” says Sil. 

"In Haryana, many people rely on unqualified practitioners, but they also seek assistance from qualified professionals. The government's strategy of deploying Multi Purpose Health Workers (MPHW), Community Health Officers, and ASHA (Accredited Social Health Activist) workers at a ratio of approximately 1 per 5,000 people has significantly improved access to healthcare services at the grassroots level," explains a medical officer from the Haryana Civil Medical Services.

Concerns of infrastructure and manpower 

However, public health facilities in Haryana continue to face significant challenges. For instance, many of these facilities are still operating in private buildings or rented houses. "Due to ownership issues, employees often adopt a 'not my land, not my job to maintain it' attitude," she discloses, anonymously. Additionally, coordination with other departments such as the Public Works Department (PWD) or Fire Services, as well as discussions regarding major structural changes, often result in communication gaps and delays.

But even with the availability of qualified personnel and infrastructure, hospitals may fail to provide quality medical care, according to the Additional Chief Medical Superintendent at a reputed hospital in West Bengal’s Bardhaman district. 

“To compensate for the lack of manpower, we often hire medical and paramedical staff on a contract basis. It lifts the burden of accountability off the permanent medical personnel. In private hospitals, there is a culture of hire-and-fire, which necessitates a responsible outlook towards patients. But in our hospital, permanent employees usually get away with lackadaisical behaviour because their jobs are insured. It creates a chasm between permanent and contractual employees, where the former usually gets an undue advantage over the latter just on the basis of their employment status,” he says. This has, with time, impacted people’s perception of government hospitals.

“The unwillingness of the paramedic staff, and sometimes even of doctors, has led to people losing faith in government-aided facilities. Thus, even when they have the opportunity of being treated at a government hospital for a fraction of the cost of a private clinic, they choose to shoulder the impossible financial burden and opt for private setups,” emphasises the superintendent.

Attempts to attract more people to avail of public health centres

Mumbai-based Dr Ishwar Gilada, President of AIDS Society of India, believes in order to encourage more people to use government facilities, health education is non-negotiable. "Raising awareness about health-seeking behaviour, especially concerning illnesses manageable at home versus those requiring professional care, is crucial," states Gilada. "Rather than relying solely on healthcare workers to reach remote areas, comprehensive vaccination awareness programmes should be implemented. These initiatives would bring communities together to learn about available healthcare facilities and services.”

“In the Rajasthan model, government doctors are allowed to offer consultations at the primary healthcare centre outside of their regular working hours. The fees collected by the doctors during these consultations are divided between the healthcare centre and the doctor. This optimises the utilisation of government facilities while also providing an incentive for doctors to earn additional income,” explains Gilada. 

Sujaya Krishnan, former Joint Secretary, Ministry of Health and Family Welfare, also believes that the penetration of healthcare throughout the country can be enabled through a care-seeking attitude. “One of the primary hurdles in providing adequate mental healthcare is the scarcity of well-trained professionals, compounded by public ignorance and pervasive stigma and discrimination. An effective coordination among government mental health institutions, non-governmental organisations (NGOs), and community-building organisations is essential to promote a culture of seeking help within the general population. While waiting for an increase in the number of mental health professionals, the focus also should be on training and educating community healthcare workers at the state level to expand outreach efforts," she explains. 

Currently serving as President of Venu Charitable Society and Member of the Guild of Service and working closely to address concerns of elder care and mental health, Krishnan elaborates that a significant step in promoting help-seeking behaviour is to incorporate mental health facilities within hospitals rather than having separate clinics.

"To combat the stigma surrounding mental health, it's crucial to implement effective strategies that integrate mental health services into general healthcare, similar to the approach proposed for the newly established AIIMS to have its specialised department for mental health and neuroscience," points out Krishnan.

Is public-private partnership the future?

According to Dr Sriradha Chatterjee, a senior registrar at Department of Acute Medicine at Lincolnshire Hospital (UK), the private sector can never replace the scale of the government infrastructure. But it shouldn’t aim to either. 

“The private sector should aim to work alongside the government, to equip the existing setups, to improve them. By actively participating in research and development, enhancing diagnostic capabilities, and supporting innovation in healthcare modalities, treatments, and equipment, they can significantly impact the advancement of the healthcare sector,” she says. 

Jury’s still out on the impact of medical tourism on India's current healthcare infrastructure, with the medical community posing opposing arguments. Chatterjee asserts that medical tourism has not substantially improved local hospital infrastructure. “This is primarily because medical tourism is predominant in well-established private hospitals that already possess sufficient private funding, resources, manpower, and infrastructure. Government healthcare facilities, on the other hand, see limited to no participation in medical tourism endeavours,” she says. 

However, according to Gilada, medical tourism remains an underutilised concept despite its immense potential.

He illustrates the case of Hepatitis C treatment, which previously amounted to a staggering US$84,000. This cost, driven by a US$ 1,000-per-tablet drug, posed significant barriers for low- and middle-income nations. However, India revolutionised accessibility by offering alternative treatments at a fraction of the global cost.

“If anything, there is a pressing need for India to further leverage its resources and bolster medical tourism. India provides exceptionally affordable healthcare treatments compared to many other countries, and this also results in a significant influx of revenue for the nation,” signs off Gilada. 

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