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    1                                                Introduction




    1.1 OBJECTIVES
    The wealth of a country is judged among other things by the health
    of its citizens. Worldwide, countries are seeking to provide viable
    healthcare solutions to its population. Improvement in healthcare
    in a society means more than the availability of doctors or hospitals
    or medicines. Improvement in healthcare occurs through promotion
    of health consciousness through a range of activities that would
    suit to various sections of the society – children, youth and elders.
    In this perspective, Indian traditional healthcare systems such as
    Ayurveda and Yoga, as also the concept of spiritual healings are
    popular amongst both domestic and international tourists.
         It is generally considered that a person who travels from one
    region (or a country) to another for the purpose of undertaking
    treatment is a healthcare tourist. However, this definition excludes
    people who travel to another region (or a country) to explore, enjoy
    and rejuvenate, either the body or the mind or both without
    undergoing medical treatment. Flow of tourism is far higher in
    absolute number as well as volume of business generated if the
    latter aspect is taken into account. Tourism to, and associated
    activities to places like sea-side, mountains, river-beds, forests,
    plains, valleys, temples or historic monuments provide rejuvenation
    to the body and mind and thereby bestow the overall well-being
    upon the person involved with such activities.
       India has many tourist attractions that have healing abilities
    and are capable of providing rewarding experiences of life. India

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    has the Himalayan ranges in the north, and a long coastline
    surrounded by three seas in the south. In addition, India is rich
    varied different landscapes, enchanting historical sites and royal
    cities, clean beaches, serene mountain retreats, cultures and
    festivities to enjoy and rejuvenate.
         In any part of the year, India can offer a wide selection of
    destinations and experiences. In summer, there are lonely retreats
    in the Himalayas or the lush-heights of the western Ghats with
    cool trekking trails, tall peaks, or stretches of white water for the
    adventure seekers. In the cool Indian winter, cities come alive with
    cultural feasts of music and dance. The sun-claud beaches are
    ideal locations for rejuvenation in the winter. The wild-life
    sanctuaries with their abundance of flora and fauna provide delights
    to the mind and rejuvenation to the body.
        The objective of this study is to review the tourism scenario in
    the world market and India, analyse the healthcare demand in the
    world, identify the healthcare and tourism solutions available in India
    to cater to the demand and to benchmark India with other
    countries, considering exclusiveness of India in various segments
    of tourism and healthcare solutions.

    1.2 CONCEPT
    Though the concept of healthcare tourism is thousands of years
    old, it has got its prominence rather recently. In ancient Greece,
    pilgrims and patients came from all over the Mediterranean to the
    sanctuary of the healing god, Asklepios, at Epidaurus. In Roman
    Britain, patients took the waters at a shrine at Bath, a practice
    that continued for 2,000 years.
         Since 18th century, wealthy Europeans travelled to Spas in
    the Nile. In the 21st century, relatively low-cost air travel has
    facilitated the growth of the industry, as travelling across continents
    has become affordable to even middle class population. Currently,
    healthcare tourists are travelling in large numbers to countries /
    regions, where the quality of healthcare is at comparable standards
    and yet the cost is significantly lower. Such healthcare destinations
    also offer numerous options for touring, sight-seeing, shopping,
    exploring and even lounging of healthy diets. The evolution of
    healthcare tourism in the world is depicted in Exhibit – 1.

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    Healthcare Tourism: Opportunities for India

                                Exhibit 1:
                     Evolution of Healthcare Tourism




     Source: Adapted from Issue – 11, 2006, Asian Hospital and Healthcare
     Management, SPG Media (P) Ltd, Hyderabad.


    1.3 DEFINITION
    According to World Tourism Organisation (WTO), “Tourism
    associated with travel to health spas or resort destinations where
    the primary purpose is to improve the traveller’s physical well being
    through a process comprising physical exercises and therapy,
    dietary control, and medical services relevant to health
    maintenance” is defined as Medical Tourism. However, “Medical
    Tourism” and “Healthcare Tourism” are interchangeably used.
         The term medical tourism has emerged from the practice of
    citizens of developed countries travelling to developing countries
    around the world, to receive a variety of medical services, mainly
    due to continually rising costs of the same services and
    complicated procedures to avail such medical services in their
    home countries. Thus, medical tourism can be defined as provision


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    of ‘cost effective’ private medical care in collaboration with the
    tourism industry for patients needing surgical and other forms of
    specialized treatment. Thus, patients going to another country for
    either urgent or elective medical procedures could be defined as
    medical tourists. This process is being facilitated by the corporate
    sector involved in medical care as well as the tourism industry -
    both private and public.
        Healthcare tourism, however, could be defined in a broader
    perspective. Patients travelling abroad with the objective of overall
    wellness, without any urgent or elective medical procedures, may
    also be covered under the healthcare tourism. Healthcare tourism
    thus could become a common form of vacationing, and covers a
    broad spectrum of healthcare services, mixing with leisure /
    relaxation, with the overall objective of wellness and healthcare.
    The objective of the healthcare tourism is to offer an opportunity
    to be away from the daily routine and come into a different
    surrounding for relaxation. During the stay, the tourist receives an
    orientation that will help improve life in terms of health and general
    well being. It is like rejuvenation and cleansing process at all levels
    - physical, mental and emotional.

    1.4 HEALTHCARE IN A BROADER PERSPECTIVE
    There are two major types of healthcare solutions in the world –
    a) traditional or indigenous system, and b) allopathic or modern
    healthcare system. While the latter can be defined as
    ‘cosmopolitan’, as they are not limited to a region or territory,
    acceptance of the former as a valuable healthcare solution is
    increasing all over the world. The renewed interest in using
    traditional healthcare solutions is mainly due to the advantages of
    minimal side effects and recognition of time-tested health solutions.

    1.4.1 Traditional Therapies
    In many countries, the citizens have varied health seeking
    behaviours with the prevalence of multiplicity of medical or healing
    systems. Many of these systems have evolved over a period of
    time, due to competitive environment and have gone through
    changes in healing solutions. In a competitive environment, some
    of these healing systems either may get absorbed by a dominant
    healing system or probably die out. A healthcare system may thus

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    Healthcare Tourism: Opportunities for India

    be defined as ‘a pattern of social institutions and cultural traditions
    that evolves from deliberate behaviour to enhance health’. It should
    be, against this background, noted that every healing system is a
    service that is being availed by a particular group of people. With
    the globalisation, the spread of such systems is also faster with
    more number of people going for diverse therapies that are
    originally unique to a country. When the end users move to another
    region or territory, they may be called healthcare tourists. In the
    context of India, notable traditional healthcare systems that are
    attracting international travellers include Ayurveda and Yoga.
        In addition to indigenous therapies / healthcare systems, there
    are also healing solutions that are prevalent in different societies.
    One such healing solution popular across the world is faith healing
    or spiritual healing.

    1.4.2 Faith / Spiritual Healing
    Faith healing refers to healing that is believed to have occurred
    supernaturally, as a result of prayers or other forms, rather than
    through the use of medicines or the involvement of physicians.
    Such healing services are often referred to as miracles. Since
    such healing solutions are available only in some parts of the world,
    it is important for people from other regions to travel for availing
    such healing services.
         The concept of spiritual tourism is not well defined. In a general
    context, spiritual tourism can be interchanged with religious tourism.
    However, religious tourism (pilgrimage) is one of the various forms
    spiritual tourism. It may be mentioned that pilgrimage used to be
    one of the oldest forms of tourism flows all over the world. Pilgrim
    centers such as Mecca, Jerusalem, temples in India are attracting
    large flow of tourists since many years. Religious events such as
    Kumbha Mela have also been traditionally attracting large number
    of tourists. Spiritual tourism adds to this form of tourism by
    travelers who are looking for a meaning while on vacation. Thus,
    spiritual tourism, in a broader context, also includes availing of
    healthcare systems that are providing psychological peace, mental
    strength, and inner-purity. Many concepts and solutions could be
    brought under this umbrella, such as journeys to sacred places,
    Yoga / meditation camps, or even trips focusing on astrology and


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    mythology. However, in the context of popularity and origin of India,
    we may mainly highlight Yoga as one such solution.
         At present, spiritual tourism is one of the fastest growing
    segments in the travel industry worldwide. The growing
    individualism in our society has led to the growth of spiritual tourism.
    Exhibit – 2 explains the commonly used methods of spiritual
    healing.
        There are mainly non-economic dimensions in spiritual tourism.
    In general, the faith healers do a free service with the objective of
    providing health for all; however, a nominal fee is charged for
    undergoing a structured healing course. In many cases, the healers
    keep a box to receive offerings, which shows that the fees collected
    are not under compulsion.
         Large number of tourists are travelling to destinations that offer
    spiritual healthcare / faith healing. National governments are also
    promoting spiritual tourism considering its potential. Government
    of Malaysia, through the Tourism Malaysia promotes spiritual
    tourism with the existing tourism circuits of Hindu temples, Chinese

                            Exhibit 2:
              One or More Methods of Spiritual Healing




     Source: Exim Research


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    Healthcare Tourism: Opportunities for India

    shrines, mosques, churches and gurdwaras. Malaysia Tourism
    promotes religious festivals, such as Lantern festival of Chinese,
    St. Anne’s Feast celebrated by Christians and ‘Thaipusam’ festival
    celebrated by Hindus to attract large number of tourists from all
    over the world. Faith healing in Nepal, a neighbouring country to
    India, dates back to the pre-historic times with the Shamans using
    tantric spirits to heal the people. Philippines promotes spiritual
    tourism and projects the country as ‘international Mecca of spiritual
    tourism’.

    1.5 FEATURES
    There are some distinguishing features of healthcare tourism which
    are outlined below:
         One of the important features of healthcare tourism is that it
    is not an impulsive activity. However, packages are woven with
    attractive features to draw the tourists. Another important feature
    of healthcare tourism is the willingness to spend. While, the cost
    of packages are attractive to wealthier segments, this may not be
    working in favour to attract patients from poorer countries. In such
    a scenario, the non-availability of such facilities in the home country
    and the quality of services provided in the host country play an
    important role.
         Healthcare tourism is also non-seasonal. This attribute can
    either be used to buffer seasonal business for resorts and location-
    specific properties, or as the main business itself. Some countries
    such as Thailand are promoting healthcare tourism as main
    business for the properties developed for this purpose. In India,
    some of the hospitals / healthcare centres in Kerala that provide
    Ayurvedic treatment adopt this model of business. The non-
    requirement for custom-builds is a strong characteristic in favour
    of the hotels. The patient and the family in this model stay in hotels
    during pre-operative and to some extent during the post-operative
    periods.
        Another important feature of healthcare tourism is that the
    average duration of stay is longer as compared to the conventional
    corporate / holiday travel. Depending upon the procedures and
    nature of treatment, the average stay of a healthcare tourist ranges
    between two weeks to two months. For example, procedures as

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    complex as open-heart surgery, including post-operative care,
    involve a stay for at least two weeks.
        It has been reported that the persons who travel outside the
    country seeking low cost healthcare are predominantly uninsured
    or underinsured population in developed countries. In addition, the
    new trend is that the corporates in developed countries are
    increasingly sending their employees to low cost healthcare
    destinations to reduce the expenditure on healthcare for their
    employees.
        Successful treatment associated with satisfactory services are
    considered as important factors for getting repeat business, as
    healthcare tourism is not a one time business. In conventional
    tourism, the satisfactory services alone are enough to get repeat
    business.

    1.6 GROWING DEMAND
    People travel for availing healthcare services in another country
    for various reasons. Tourists from the United States are primarily
    travelling to other destinations as the cost of getting treatment in
    home country is costlier by four to ten times depending on the
    treatment procedures. Many tourists from European countries
    primarily travel to other destinations due to the complexity of availing
    the healthcare services in their home country. Some of the tourists
    from Middle East and Africa region, travel due to affordability of
    treatment and quality of services rendered. A section of people
    travel to India purely on the basis of the availability of specialty
    healthcare services, such as Ayurveda, Yoga. Healthcare centres
    set up for this purpose attracts tourists with specialty healthcare
    services that are not associated with any emergency medical
    services.
        In developed countries, there are increasing trends towards
    acceptance of Indian healthcare systems such as Ayurvedic
    therapies and Yoga. Growth of middleclass population in developing
    world and increasing interest in the industrialised countries has
    greatly increased the demand for Indian healthcare systems. With
    the growth in low-cost airline traffic, the feature of affordability works
    in multiple ways and brings in more population as healthcare
    tourists.

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    Healthcare Tourism: Opportunities for India

         Many people from the developed world are coming to India
    not only for the rejuvenation, promised by yoga and Ayurvedic
    therapies, but also for urgent medical treatment such as hip
    replacement, heart or brain surgery. The combination of high quality
    and low cost services is also attracting repeated stream of
    international patients.

    1.7 HEALTHCARE TOURISM : ONE FORM OF TRADE
        IN HEALTHCARE SERVICES
    Many countries probably did not think of health care as something
    that is traded internationally. However, it is being increasingly offered
    cross-border in two ways (Exhibit – 3).
        Vast majority of cross border health care services are availed
    by the patients from developed countries, by undertaking travel to
    the host countries, which are increasingly developing countries. In
    such cases, the services are very specialized and are either
    available at low cost or a decision to purchase the service was
    taken after waiting for long period in home countries. This category
    of trade in healthcare services also includes unplanned
    emergencies that may occur when a foreigner falls sick or injured
    while traveling to other countries. In such cases, neither the service
    nor the service provider crosses a border; instead, the patient goes
    to where the service is available. Consequently, this is not typically
    considered as trade in the way it is generally understood, although

                              Exhibit 3:
                    Two Forms of Trade in Healthcare




     Source: Exim Research


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    some suggest that it should still be considered as trade in health
    care services.
         Another form of trade in healthcare services would be when
    the healthcare services cross the border, the service provider as
    well as the patient stay wherever they are. This type of cross
    border trade in healthcare services happens with the advancement
    in communication technologies. The use of advanced diagnostic
    testing technologies, satellite communication, tele-health
    consultation, and the Internet may make it possible, and perhaps
    even desirable, for a patient from one country to get the advice
    and expertise of highly regarded specialists in other countries. In
    fact, there are examples of physicians being able to assist in
    surgeries through satellite transmissions linking a doctor in one
    country with a surgery being performed in another country. Such
    form of trade in healthcare services are minuscule at present;
    however, with the advent of technology, trade in health care services
    under this mode is likely to become increasingly common.

    1.8 IN SUM
    The demand for healthcare services is growing and many countries
    are competing with each other for a share in the global healthcare
    tourism demand. Developing countries are in an advantageous
    position, as the cost and complexity of providing the services are
    relatively low. India stands to gain with the increasing demand from
    abroad for availing of healthcare services from abroad. However,
    the competition will be tough as other countries are finding
    innovative ways to attract the tourists. It is, in this context,
    appropriate to analyse the growing demand for healthcare services,
    as also the models of other countries that are projecting
    themselves as healthcare destinations.




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