India’s Holistic Promise

REALISING INDIA’S HOLISTIC PROMISE

India is at the cusp of a massive upscaling of its healthcare services exports. IBT analyses the critical action points for stakeholders to capitalize on this unique window of opportunity.

BY VIRAT BAHRI

Alot has been said about how healthcare was ill-equipped to handle the once-in-a-century COVID crisis. But that is precisely the thing about such crises – you don’t face them every day, and have no precedents to even consider a structured response. And when they come, you are pushed into a difficult corner, and compelled to make radical transformation. Time is a huge luxury that’s not on your side.

The pandemic exposed critical deficiencies that Indian healthcare needs to address, especially with lack of infrastructure and equipment – beds, medical staff, PPEs, oxygen, diagnostic kits, etc – and healthcare staff. As cases rose exponentially, even hospitals in tier 1 cities struggled to cope, especially in the second wave.

But these constraints alone do not define the Indian healthcare sector. When you look at India’s impressive rise in medical tourism, one could argue that the glass is actually half full. India has a number of stateof-the-art healthcare facilities with demonstrated capability for simple to complex medical procedures and excellent post-operative care at highly economical prices. Indian doctors and healthcare workers are recognized as being among the best in the world.

As per latest estimates, the country has 37 Joint Commission International (JCI) accredited hospitals and 513 hospitals accredited by the National Accreditation Board for Hospitals & Healthcare Providers (NABH). Apart from this, India has distinct advantages with AYUSH and wellness therapies, which have been gaining recognition over the years.

According to the Tourism Ministry, India’s medical tourism was valued at US$ 3 billion in 2015, and grew to US$ 5-6 billion in 2020. Postpandemic, the government is looking to take up a larger share of the medical value tourism pie, estimated at US$ 60-80 billion globally. Wellness is way larger at US$ 639 billion

INDIA HAS A NUMBER OF STATE-OF-THEART HEALTHCARE FACILITIES WITH CAPABILITY FOR SIMPLE TO COMPLEX MEDICAL PROCEDURES AT ECONOMICAL PRICES.

(Global Wellness Institute, 2017).

The health and wellness sector has huge potential & scalability to grow its share in India’s services exports. The country is projected to create 1 million health professionals every year, which can be juxtaposed with a projected global shortage of 12.9 million professionals by 2035. This cover story discusses key strategies to help realise this vision.

EXPANSION & DIVERSIFICATION

As mentioned, India is a leading destination for medical tourism (Mode 2), due to the presence of highly skilled and professional healthcare personnel, world class doctors and high quality healthcare at economical prices. Foreign tourist arrivals in India stood at 697,000 in 2019 compared to 495,056 in 2017, which indicates growing recognition and preference.

The Government of India has announced the twin initiatives of Heal in India and Heal by India to promote Indian healthcare internationally. The former is focused on medical tourism, wherein the government is looking to ramp up medical infrastructure at 37 hospitals across 12 states, according to reports. It will also include interpreters and special desks at 10 identified airports, a multilingual portal and simplified visa norms for international patients

and their companions. Moreover, it has identified 44 target markets, which are mainly from Africa, Latin America, SAARC and Gulf regions.

Under Heal by India, the government is looking to leverage India’s strengths as a source of trained and competent manpower in healthcare (Mode 4). The Health Ministry is developing an online repository of healthcare professionals, including doctors, nurses and pharmacists, which will also mention which nation they wish to render their services. At the same time, it is developing a repository of hospitals, where NABH accreditation will be necessary to treat patients abroad. These initiatives will go a long way in facilitation and confidence building among foreign patients visiting India, and foreign hospitals seeking professionals.

The COVID pandemic has caused a rapid increase in digitization of healthcare, with ‘contactless’ becoming the norm. Wearable tech, telemedicine, VR, robotics, and AI were readily adopted by hospitals, and are expected to transform the healthcare landscape in the coming years. The National Digital Health Mission aims to bring healthcare records online to improve efficiency and reduce costs, thereby ensuring better outcomes. Tele-consultations played a major role in reducing hospital visits and ensuring patients continued to get the right guidance even in the middle of lockdowns.

Remote consultations can be catalytic in taking healthcare to the last mile, and could also enable a strong revival for India’s medical tourism. Through digital delivery, patients can avoid unnecessary trips and the associated costs. Dr Pralok Gupta, Professor, Centre for WTO Studies and Member, Committee of Advanced Trade Research, TPCI, illustrates with an example, “A kidney transplant procedure is not limited to the surgery and recovery period of 10-15 days. It requires a continuous attention for a prolonged period of time and follow up on aspects like medicines and precautions to be taken. But it may not be possible for the foreign patient to visit India again

GROWTH TREND IN INDIA’S HEALTHCARE SECTOR

400

350

300

250

200

150

100

50

0 81

2014 104 110 160 280 372

2015 2016 2017 2020F 2022F

Source: NITI Aayog; figures in US$ billion

and again every month.” This is where Mode 1 would be very helpful. The technologies developed by India to enable remote healthcare could also be a sunrise export opportunity targeted at developing nations/LDCs in particular.

Another favourable development is the growing importance of AYUSH therapies for boosting overall health and well-being and boosting immunity. Exports of Ayush and herbal products were at US$ 539.57 million during 2020-21, as compared to US$ 425.80 million during 201920, according to Ministry of Ayush. On the other hand, the domestic market of Ayush products, has also increased and is projected at US$ 23.3 billion in 2022 (RIS).

With a strong intent to increase their adoption, standardization of Ayush-based health services is already on the rise. Dr D C Katoch, Senior CMO (Ayurveda), CGHS, informs, “India now has over 70 NABH-accredited Ayush hospitals across the 3Ps – practice, practitioner and product with quality control mechanisms and standardization. Even the Bureau of Indian Standards has taken up standardization of materials used in Ayush systems other than drugs.” In fact, they even brought in standards for the mat for performing yoga.

Many premier hospitals in the country now have Ayurveda and yoga units. Many Ayurveda hospitals were converted into COVID hospitals in the past 2-3 years. Dr Katoch adds, “Pure Ayurvedic treatment or Ayush treatment was given to mild cases for prevention or during quarantine for moderate cases. And the success rate was excellent.” During this outbreak, as many as 68 clinical trials related to Ayush drugs, were registered in the Clinical Trial Registry of India (CTRI).

Governments are now more cognizant of the gaps in healthcare infrastructure & personnel. So they are relaxing their visa norms for specific categories of paramedics, nurses and doctors. India is evidently best placed with the competence and scale to bridge these critical gaps.

Dr Upasana Arora, Director, INDIA’S IMPORTS & EXPORTS OF HEALTH-RELATED SERVICES

180

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0 109.23

32.30 144.91

31.08 160.27

19.07

2018 2019 2020

Export Import Source: I-Tip (an initiative of WTO & World Bank); Figures in US$ million

Yashoda Super Speciality Hospital, affirms, “Other countries are offering Indian hospitals to come, promising free of cost land, to set up and provide healthcare services. At the same time, few countries face shortage of skilled doctors, nurses, etc. They would like Indians to provide treatment to their citizens.”

REALISING THE POTENTIAL

India is well poised for a giant leap as a global healthcare hub, with its advantages of manpower, scalability, traditional knowledge, quality & personal care and cost. Our discussions with stakeholders revealed recommendations in four prominent areas – incentivising investments for infrastructure enhancement, leveraging technology to overcome current physical constraints, tapping emerging trade opportunities, promoting AYUSH and wellness and boosting quality.

To quote a pandemic data point, according to the Ministry of Health and Family Welfare, the country had around 1.5 million isolation beds across 15,375 dedicated treatment facilities at the end of the first wave. This is over 1 bed per 1,000 people, and just around 18% of these were oxygen supported. Overall, India has 5.2 beds per 10,000 people.

The doctor-to-patient ratio at 0.7 per 1,000 population compares quite unfavourably to the WHO average of 2.5 per 1,000. Government expenditure on healthcare increased from 1.15% in 2013-14 to 1.35% in 2017-18. The global benchmark

is the US, with a share of 16.9%. India’s figure is quite low even in comparison to BRICS members, where public spending in healthcare is between 4-6% of GDP.

However, the private sector has been playing a major role since the 1980s, with an estimated expenditure of around 3.6% of GDP. It accounts for around 65% of primary health care services and 85-90% of tertiary care. However, Dr Girdhar Gyani, Director General, AHPI (India) cautions that bulk of investments are coming from overseas, and there is a need to enhance domestic investments. For this, he recommends ease of doing business and single window clearance.

Moreover, hospitals need to be provided with soft loans for expansion, and provided essential services like electricity at industrial or domestic rates (currently being charged commercial rates). He also feels that private sector should be incentivized to set up satellite hospitals in, say a radius of around 100 km. Doctors from the main hospital can travel to satellite hospital for emergencies, and handle routine treatments through telemedicine.

The revised health policy focusing on universal health coverage is a paradigm shift. Ayushman Bharat insurance cover and Digital Health Mission are expected to take healthcare to the masses. Central & State Governments are working on increasing MBBS seats, which have doubled to nearly 100,000 seats since 2014. Enhancing the number of post-graduate doctors can also be explored to improve the supply of medical specialists.

India can certainly emerge the destination of choice and garner a huge share of the health and wellness tourism market by building on past momentum, but this requires work on brand promotion, enabling infrastructure and end-toend facilitation. For capturing the wellness market, the Kerala model of accredited wellness centres needs to be replicated in other states.

Mode 1 is lucrative, but could run into data security hurdles, which are emerging as a significant factor in trade. It will be difficult to get patient data from a country like EU, which is very stringent on data regulations. Moreover, mutual recognition of service providers is a major challenge. Although there is liberalization in Mode 4 movements, it is limited to specific categories. The relaxations being provided need to be analysed and supply mapped accordingly. Moreover, regulators need to be tactically brought on board to ensure mutual recognition.

This is also true for AYUSH, as Dr Katoch points out, “During FTA negotiations, whenever we talk about including Ayush products, the first major hurdle is that the equivalent product is not there in that country. Moreover, Ayush products in India are exported in the form of food supplements, dietary supplements, self-health foods or general health products. So they are not recognized there as drugs.”

Market authorization challenges need to be addressed, therefore, and the same goes for functional integration with AYUSH into mainstream medical care. Dr Katoch adds, “Even today, while more than 70% of PHCs, CHCs and district hospitals in India have Ayush facilities, the practitioners are not working in collaboration with allopathic doctors. This is necessary to provide maximum benefit or optimize health care delivery to people.” Aggregating Ayush and allopathic doctors can help India surpass WHO benchmarks and take health coverage to the last mile.

Last but not the least, strict adherence to quality benchmarks is essential. Dr Atul Kochhar, CEO, NABH, affirms that SOPs proved a key differentiating factor for hospitals amid the outbreak, when it came to controlling mortalities of patients and healthcare workers. He surmises, “So that is a very strong case to institute SOPs in every domain of healthcare, whether they go for NABH certificate or not. The basic framework of patient safety revolves around having process centered care not person specific care.” Standardisation is a core foundation on which Heal in India and Heal by India can be achieved.

THE NUMBER OF MBBS SEATS HAVE DOUBLED TO NEARLY 100,000 SEATS SINCE 2014. ENHANCING THE NUMBER OF SEATS FOR POST-GRADUATE DOCTORS IS ALSO NECESSARY TO INCREASE THE SUPPLY OF SPECIALISTS.