Cross-border social relations, thanks to globalization, have shaped a world where transnational commerce and international migration can impact global health. From a human rights perspective, the responsibility of global health is an internationally shared one, as the causes and consequences of medical issues can circumvent territorial boundaries. This has led to the creation of commerce surrounding global healthcare, and has prompted developing countries like India to build policy frameworks that promote health-related tourism and offer incentives and special facilities to medical tourists — but at what cost? In this article, I will be discussing the phenomenon of medical tourism in India and assessing the gaps in its policies and practice.
Although initially considered a novelty practice, medical tourism has been recognized as a service by the World Trade Organization (WTO), making it a global occurrence in conjunction with the “consumption of healthcare services abroad” clause of Mode 2 of the General Agreement on Trade in Services (GATS). Medical tourism marries two important features of international trade in service — tourism and healthcare — which are exported within a country’s own boundaries for patients to travel and consume. Over the past two decades, India has emerged as a major hub of medical tourism in the global South, with studies claiming that the number of medical tourists in India has tripled between 2002 and 2005, and the sector has been projected to earn around US $20 billion in revenue by 2020. The 10th and 11th five-year plans by the Indian Planning Commission also stressed on the importance of the development of private-sector healthcare tourism, recommending the promotion of India as a high-tech, low-cost destination for medical procedures and treatment. The website for healthcare tourism by the Services Export Promotion Council highlights wellness, rejuvenation, Ayurveda, and alternate medicine as attractive features of Indian healthcare offered to foreigners.
The belief that foreign patients rake in high revenues and foreign exchange has led to an increase in new market opportunities in India, leading to a decline, to some extent, in international medical brain drain. Rather, the brain drain seems to be from medical professionals working in the public sector to the private sector. Following recommendations by the UN Sub-Commission on the Promotion and Protection of Human Rights (2002), the Indian Government implemented a number of policy initiatives that have encouraged the participation of the private sector in medical tourism. In 2003, the Centre introduced a private-public partnership policy for infrastructure, which included contracting subsidiary healthcare facility services and the outsourcing of management in public hospitals. Apart from this, numerous large-scale policy initiatives included a reduction of customs duties for certain kinds of essential medical equipment, relaxed taxation for long-term capital investors of hospital projects, and most importantly, the establishment of a “medical visa” which would facilitate the entry of foreigners seeking healthcare facilities in the country.
The medical visa is set up to help international visitors who have sought primary medical counsel from their home countries, and have been advised specialized medical procedures or treatments that are available in India. Along with its Incredible India campaign, the Ministry of Tourism (MoT) has emphasized its provision of medical visas and encourages medical tourists to return to the country for treatment, and this has been done via various initiatives, from promotion in overseas markets to financial assistance to service providers, and the publication of various films, brochures, and other publicity materials. The video testimonial below was uploaded by Apollo Hospitals in a bid to garner more foreign patients to choose their facility for their treatments:
According to the Ministry of Home Affairs (MoHA) in 2011, the medical visa was introduced for security purposes, and set a mandatory condition for foreigners visiting India on this visa (and the medical attendant visa) to register at a relevant foreign registration office within 14 days of arrival. Theoretically, this process would ensure that the relevant authorities would have a reliable record of foreigners entering the country on a medical visa. Yet, when UK-based law professor Swati Gola inquired about such a registry, it was found that no such central register or format existed to record these details. Neither the agencies that issue medical visas abroad, nor those who record the entry of visitors at immigration check posts, nor those at the designated registration offices seemed to maintain information on foreign national patients who have visited India on medical grounds and completed the mandated registration.
Gola, on filing multiple Right to Information (RTI) requests to the 28 States and 7 Union Territories at the time, found that many responses claimed that the public authorities entrusted with the responsibility of documenting medical tourists were exempt from being answerable under the RTI. Yet, 13 responses provided certain basic details of registered foreign medical visitors. The request was for information in the form of the year, country, and medical condition for which the tourists entered the country. Responses varied from either no response, to providing as far as the names and passport number of the patient. These contradictory responses to the same RTI prove an inconsistency and disparity in the system regarding the confidentiality of medical tourism cases, as well as the powers of the executive bodies in question.
What is more baffling is the diffusion of responsibility among Ministries in the Indian government. The Central Ministry of Health and Family Welfare (Health Ministry) in 2002 adopted a National Health Policy which allowed for the provision of secondary and tertiary healthcare to foreign patients on a payment basis. However, the Health Ministry has never conceptualized any policy to engage with medical tourism, neither has it had any consultations with the MoHA with respect to the designing of the medical visa. In fact, the Health Ministry has no actual policy on medical tourism; rather the entire migration is coordinated by the MoT. Furthermore, despite public health being a State responsibility, the Health Ministry is still accountable for the governance, funding, and policymaking that assist States in executing their health-related tasks. Medical tourism is one such public policy, and the role of the Health Ministry should be increasing as its facilitator and coordinator, given that international trade policies and negotiations could have negative outcomes on the public health of India’s underprivileged communities.
Despite the fact that the main aim of tourists entering India on a medical visa is not to engage in recreational activities but primarily to utilize healthcare services, the MoT has taken up the duty to promote this segment of the economy. As evident, the Health Ministry has diminished its role in medical tourism, even though the sector has a large potential to impact the healthcare facilities provided to the country’s huge domestic population. The policy initiatives undertaken by the MoT to encourage medical tourism find their basis in the neoliberal claim that economic growth through this sector will trickle down to benefit public medical services. To understand this better, it may be interesting to look at the most famous case study in recent medical tourism history — that of Eman Ahmed Abd El Aty, an Egyptian national who was the world’s heaviest woman at the time.
Eman came to Mumbai’s Saifee Hospital in February 2017 to be operated upon by Dr Muffazal Lakdawala, a leading bariatric surgeon. Eman’s inability to physically show up at the Indian Embassy in Cairo initially led to a visa refusal; however after Lakdawala appealed to Sushma Swaraj (former Minister of External Affairs (MEA)) on Twitter, a medical visa was granted. Eman was brought to Mumbai by an EgyptAir freighter aircraft in a specially crafted bed and was transported from the airport to the hospital in a custom-modified truck that was covered by all sides. The hospital authorities constructed a 1000 sq. ft. facility on the first floor to house Eman, after the Brihanmumbai Municipal Corporation (BMC) demolished ground floor structure they created specifically for Eman citing a lack of authorized permissions. A few months after a successful surgery by Lakdawala and his 13-member team, Eman’s sister Shaimaa had a falling out with the doctors, where she alleged that they lied about Eman’s progress and weight loss. She released a video of the patient on social media, which backed her claims that Eman had suffered from three strokes and bed sores post-surgery. Later on, Eman was taken to Burjeel Hospital in Abu Dhabi, where she eventually passed away.
One of the main reasons why Eman’s family approached Lakdawala for the surgery (like Dan from the video) was because of India’s low costs for bariatric surgeries — almost half the price of those abroad. Yet, according to Huzaifa Shehabi, CEO of Saifee Hospital, the hospital incurred costs of over Rs. 2 crores on Eman’s treatment, of which only INR 64 lakh were covered through public fund donations, while the balance amount was borne by the hospital itself. Such massive spending on a single patient shows the dedication of India’s private health sector to medical tourists, and it can be conferred that the alleged lies told by the doctors would be to justify such spending. Many medical activists felt that these funds could have been better utilized to enhance other departments, or to provide free healthcare to disadvantaged local communities.
So far, the opening of the Indian healthcare sector to foreign patients due to liberalization under GATS seems to have only benefitted the private sector which promises foreign patients that “to cure with care is a tradition”. The onus of providing healthcare to medical tourists lies mainly with the private sector, and the entire model relies heavily on the maximization of profits — foreign national patients are often made to occupy high-end rooms and beds, pay higher fees for the same treatments, and therefore provide more profits to private hospitals. Yet, these very private hospitals turn their backs on poor Indian patients and violate their human right to health, while also going against their contractual and legal obligations to provide treatment.
In the case of Laxmi Mandal v. Deen Dayal Harinagar Hospital and Ors, medical care was denied to a poor pregnant woman who was carrying a dead foetus for five days by four different private hospitals. One of these private hospitals was a grantee to concessionary land by the Government on the condition that it would provide free treatment and keep 10-20% of its beds to patients who fall below poverty line. This unchecked growth and lack of regulation regarding the private healthcare sector has led to a widened inequality gap due to unethical practices and increased healthcare costs, and the focus of the private sector on attracting foreign medical tourists and rich Indians will intensify this trend.
Since the Health Ministry does not associate itself with the private practice of medical tourism, big-name hospitals like Apollo Hospitals have taken full advantage of the lack of a centralized system to monitor medical tourism, and have been involved in tax evasion, as shown by a Comptroller and Auditor General of India report from 2002. Even seventeen years later, the Government of India has not commissioned any independent research study to evaluate and assess the impact of medical tourism in the country, neither has it implemented a system to monitor the practice. This shows that there is an absence of a mechanism for management, analysis, and systematic data collection to corroborate the tall claims made by authorities regarding the profitability of this practice.
There is a dire need for evidence-based policymaking in the Health Ministry to regulate the practice of medical tourism in the private sector. This is crucial in reducing inequity so that domestic patients do not lose out on their human right to health in a bid to gain profits. It is essential that the Indian administration sees health as more than a commercial sector, and consults with the Health Ministry before making any further decisions regarding this practice. The surplus revenue from medical tourism could benefit public healthcare facilities in India if the private sector were taxed adequately and encouraged to support public health, instead of the tax and other concessions discussed above. Furthermore, coordination between the Health Ministry, MEA, and MoT is crucial in documenting and assessing the movement and impact of medical tourists in the country. The Health Ministry must take a more proactive approach in checking public policies, interventions, and programmes by other ministries that have implications on public health and human rights.
References
Comptroller and Auditor General of India (2004), Chapter 3: Ministry of Urban Development and Poverty Alleviation, Government of India, New Delhi
Gola, S. (2016). Medical tourism in India — in whose interest?. Journal Of International Trade Law And Policy, 15(2/3), 115-133. doi: 10.1108/jitlp-01-2016-0005
Gupta, A. (2008). Medical tourism in India: winners and losers. Indian Journal Of Medical Ethics. doi: 10.20529/ijme.2008.002
Hazarika, I. (2010), “Medical tourism: its potential impact on the health workforce and health systems in India”, Health Policy and Planning, Vol. 25, pp. 248-251.
Safi, M. (2017). Doctors treating world's heaviest woman resign over claims they lied about her weight loss. Retrieved 14 August 2019, from https://www.theguardian.com/world/2017/apr/27/doctors-treating-worlds-heaviest-woman-eman-ahmed-resign-claims-lied-weight-loss
UN Sub-Commission on the Promotion and Protection of Human Rights (2002), Liberalization of Trade in Services and Human Rights: Report of the High Commissioner, UN Doc. E/CN.4/ Sub.2/2002/9, United Nations, Geneva.
World’s heaviest woman Eman Ahmed thanks India, Egypt for help in treatment. (2017). Retrieved 14 August 2019, from https://www.hindustantimes.com/india-news/world-s-heaviest-woman-eman-ahmed-thanks-indian-egyptian-govts-for-surgery-efforts/story-yA4JlV2dZkPTplxSeKaWqK.html
Image Credits: MedLife