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Friday, 11 October, 2019, 17 : 56 PM [IST]

Medical Tourism in India: Affordable, but is it Accessible to All

Anav Batra
The world celebrated World Tourism Day on September 27. Different focused activities took place across the world to promote tourism. In 2019, the Tourism Day got more prominence, as India was chosen as a host country for the official celebrations of United Nations World Tourism Organization's (UNWTO) World Tourism Day in New Delhi. Also, the nationwide 'Paryatan Parv 2019' kicked off on 2 October 2019 (Gandhi Ji's 150th birth anniversary) will continue till October 13, 2019 with an aim to propagate the message of 'Dekho Apna Desh' to encourage people to visit tourist destinations of the country and spread the message of Tourism for All.

While several events were organised to promote tourism in the country and showcase India as a great tourist destination which it is, one thing that somehow got missed is the crucial part of tourism i.e. medical tourism. Its enormous potentials and ability to contribute to the national GDP and create employment opportunities need to be emphasised.

India, a global hub for medical tourists, attracts colossal amounts of patients from around the world. In 2017, over 4.95 lakh (495,000) patients had come for treatment in India, while it was 2.34 lakh (234,000) foreign tourists who came for treatment related reasons in the year 2015. With the rise of medical tourists, comes significant revenue for the medical industry. KJ Alphons, Former Union Minister of State for Culture, and Tourism, while replying to a question in parliament, had also shared that India had generated estimated revenue of INR 1, 77,874 crore in 2017 alone from foreign exchange. The meteoric rise has resulted in India's medical tourism industry to be worth staggering USD 9 billion by 2020, roughly equivalent to 20% of the global market share.

The question here is, why has India become the medical tourism mammoth that it is? India has a rare mix of affordability, effective and superior clinical outcomes, up-to-date facilities, and a large variety of medical services offered to patients. For example, a heart bypass procedure costs a mere USD 5,200 in India, as compared to the enormous USD 144,000 that it costs in the USA. For those who are from lesser-developed nations, India provides a tempting choice for patients. It's cost-effective, reliable, and accurate. India provides patients from all nations with world class medical services, which cannot be found back at home, at price levels that are staggeringly low from the United States of America, and the United Kingdom. To add on, this concept can also be highly beneficial to patients from first-world countries. These patients may be looking for similar treatment care, for a lower cost, and India provides the perfect solution, right? Despite all the strengths described above, Medical Tourism in India, however, is losing many medical tourists to nationals like Singapore, Malaysia, and Thailand for variety of reasons. If we look at the data of medical tourism inflow, Bangladesh tops the list while other countries include Maldives, Afghanistan, and East African nations. There is no significant number from the first world countries.

To analyse and explore the medical tourism industry in India, research needs to be conducted on the situation of the medical industry in India. A report by IMS Health India called, "Medical Value Travel India" tried to analyse the "key considerations" of India as a medical tourism destination for patients. In it, there were six major pillars of consideration: "cost effectiveness", "clinical outcomes", "tourist friendliness", "regulatory regime", "alternate medicine", and "accreditation".

While India had been given a "high" rating for cost effectiveness, clinical outcomes, alternate medicine, it was given low ratings for tourist friendliness and regulatory regime. Why? Let's analyse step by step. First, in terms of tourist friendliness, according to the report above, the key factors that had a major bearing on the level of tourist friendliness included, "aviation infrastructure, and amenities at the airport, proper transport infrastructure, affordable accommodation, good food, adequate cleanliness, hygiene, safe drinking water and overall safety concern". The Medical Value Travel Report itself cited that amenities such as separate kiosks for medical tourists for immigration clearance, language interpreters, and ambulance services from the airport are all lacking in India. The report also addressed that better infrastructure of roads and highways would ensure to better the experience of those travelling in India. Other issues addressed were the availability of international cuisine, affordable hotels, and creating an environment of overall holistic care for medical tourists. However, although these issues raise significant questions, the report does not address a pervasive, yet often missed concept; accessibility in hospitals, accommodations available and the city infrastructure – built as well as the transportation system, particularly the intra city and the last mile connectivity.

What is accessibility, per say? Accessibility is the concept of creating inclusive infrastructure and environments for every single human being, regardless of their physical or mental conditions and abilities. Accessibility, to a large extent, is correlated to the safety and inclusion of all people. Accessibility is a very broad concept that encompasses many of the ideas portrayed in the forenamed reports; however, it is mostly missed as it is not clearly specified in the reports or requirements.

Second issue besides the tourist friendliness that the report above raises is that of regulatory regime. This could be understood from two perspectives, firstly the international accreditations of the medical institutions and secondly the regulation of built environment of the hospitals.

India has signed and ratified UN Convention on the Rights of Persons with Disabilities and accordingly has enacted the Rights of Persons with Disabilities Act 2016 which mandates accessibility in public buildings, hospitals being included. Section 15 of the Rights of Persons with Disabilities Rules 2015 provides that every establishment shall comply with the standards relating to physical environment, transport and information and communication technology. The Act even provides of penalties and strict legal action for non-compliance of the accessibility requirements. However, most hospitals in India - whether private or government, perform poorly on this front. Whether it is washrooms or flooring, signage or colour contrast, none of the hospitals can claim to be accessible.

To study the level of accessible and appropriate infrastructure that is present in the medical industry in India, real-life cases need to be examined, and most importantly, understood. On May 14, 2019, a 65-year-old patient, named Rampal, had fallen off the sixth floor to fourth floor of the Government Multispecialty Hospital in Chandigarh, by stepping into the bathroom's shaft. Rampal, severely injured, didn't survive. Now, this raises serious questions about the accessibility, safety and the appropriateness of the infrastructure in the hospital. However, this is not the only problem. More importantly, this raises the matter of the effectiveness of the signage, if used on the shaft door and why edge protection was not provided - both embody the concept of accessibility. One of the key pillars of accessibility is the concept of safety for all individuals in all infrastructure. Proper signage and security measures keep all individuals safe, as without them, dangerous consequences can occur.

Guidelines issued by CPWD way back in 1998 on barrier free environment provided that, "Municipal authorities/corporations should ensure, before giving permissions of construction, the provisions of stepless system for easy access to buildings, lifts for free access to upper floors, adequate doors width for wheelchair entry and accessible toilets." This made the concept of accessible toilets an imperative condition to hospitals around India in 1998 itself. Today we have better standards in form of National Building Code 2016. The regulatory framework around accessibility is very good however, is not implemented.

Government of India launched Accessible India Campaign in 2015 and initiated access audits of public buildings, websites accessibility etc. The access audit reports of these public buildings, many of them being very popular government hospitals, which had been conducted by many expert organisations, Svayam- Global Centre for Inclusive Environment being one of them, has been made available on the official website of Ministry of Social Justice & Empowerment, Govt. of India. Almost all the access audit reports of hospitals from various cities indicate that none of the hospital had an accessible toilet. The essential point is that humans can still manage to communicate without an interpreter, they can still, with most difficulty, be able to transfer into a vehicle with support, however, adjusting to an inaccessible bathroom, is near an impossibility for individuals with reduced mobility. Of the several access audits of government hospitals that the author referred to, sixteen hospitals were in the heart of New Delhi which present clear examples of how hospitals in the capital of India overlook accessibility, as a necessary component in a hospital.

Despite the law called The Persons with Disabilities Act 1995 that remained on paper for over 24 years and now substituted by The Rights of Persons with Disabilities Act 2016, the access audits of major public hospitals reveal that there is little enforcement of the Act.

The lack of attention towards accessibility as a whole, and particularly in terms of the toilets, can be most emphasised by the Joint Commission International Accreditation Standards for Hospitals. The Joint Commission International (JCI) is a US-based nonprofit organisation that accredits thousands of healthcare organisations around the world. However, in its 6th edition of accreditation standards for hospitals, the JCI does not mentions toilets, bathrooms, or any concept of accessibility in any section. This embodies how overshadowed the concept of accessibility is. Hospitals and healthcare organisations around the world and in India can receive prestigious accreditations without providing accessible infrastructure and facilities that all medical tourists and patients in general can use, without descrimination of their physical and mental abilities. One may argue that the JCI may have assumed that the local building laws would govern accessibility and that the hospital infrastructure would be abiding to the national laws of the country. However, in India, due to lack of strict enforcement of laws, accessibility, despite being a vital need for all people and a requirement of the statute, is often overlooked and deemed as a "minor" issue, when in reality, it is critical in everyday life.

Another aspect of accessibility is availability of information in accessible formats on the websites of the major hospitals. The author visited websites of all major hospitals operating in Delhi NCR, Chennai, Chandigarh – both private and government, none of the websites provided information about accessibility in hospitals, patient accommodations etc. In fact, most of the websites itself were not accessible complying with WCAG 2.0AA level which is a mandatory requirement of accessibility guidelines for all government websites.

The World Health Organization (WHO) in 2011 has estimated that more than 15 percent of the world population has lived with a disability and 110 million people have had difficulties in functioning. More or less everyone can face the requirement of accessible infrastructure at some part of their life (Darcy and Dickson, 2009).With an aging population, increasing traffic accidents, cardiovascular diseases, etc, the requirement of having accessible infrastructure is becoming increasingly prominent. Medical tourism is booming in India. Hundreds of thousands of medical tourists visit India, with the goal to receive effective medical assistance at a low price. India has progressed majorly in terms of its patient care, facilities, service, and outcomes; however, what it most strikingly overlooks is the infrastructure, especially from the lenses of accessibility based on universal design that benefits all.

Accessibility can also have an impact on the growth of Medical Tourism in India. Without strong enforcement, hospitals will not see the need to include accessible infrastructure, and this may hamper India's medical tourism industry. If India develops the perception of a country where accessibility is a challenge, medical tourists may look towards other countries in Asia like Singapore and Thailand, who provide similar medical care and cost-effective prices, with accessible facilities. Instead, if healthcare organisations become more accessible, perhaps it may also lead to more medical tourists from first-world countries such as the USA or the United Kingdom, to come for medical assistance in India. All in all, it seems that it is in India and the medical tourism industry's interest to make hospital infrastructure accessible and inclusive to all individuals, regardless of their physical and mental capabilities. This will not only be complying with the regulatory mechanism for accessibility of public buildings but will also add more credibility to the hospitals and attract more medical tourists from first world countries.

Sources/ Links

  • https://www.imtj.com/news/minister-state-tourism-claims-495k-foreign-patients-2017/
  • http://www.ficci.in/Medical-Value-Travel-Report.pdf
  • https://timesofindia.indiatimes.com/city/chandigarh/patient-steps-into-hospital-bathroom-shaft-dies/articleshow/69452590.cms
  • http://disabilityaffairs.gov.in/content/access_report/delhi.php
  • http://www.disabilityaffairs.gov.in/content/viewpage/rights-of-persons-with-disabilities-rules--2017-gazette-document.php
  • http://www.disabilityaffairs.gov.in/upload/uploadfiles/files/RPWD%20ACT%202016.pdf
  • https://www.jointcommissioninternational.org/jci-accreditation-standards-for-hospitals-6th-edition/
  • http://legislative.gov.in/actsofparliamentfromtheyear/persons-disabilities-equal-opportunities-protection-rights-and-full
  • https://cpwd.gov.in/Publication/aged&disabled.PDF
  • https://web.guidelines.gov.in/assets/gigw-manual.pdf
Anav Batra is a young volunteer with Svayam, India's leading non-profit working on accessibility as a human right. He is a student of American Embassy School and has lived experiences of disability since childhood, as his mother is a wheelchair user. Widely traveled and has been contributing to accessibility in his own way by influencing millennials and motivating them to raise their voice for accessible infrastructure, transportation systems and services.

(Founded by Sminu Jindal in the year 2000, Svayam works to make India more accesible for people with reduced mobility)
 
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Jayshree 2019-10-07 19:52:26
good stuff, good read, good job
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