India should explore Mode 3 in healthcare

Alternative therapies hold promise for Indian healthcare exports

Dr Rupa Chanda, Professor, Indian Institute of Management, Bangalore, talks about the prospects of India as a healthcare hub post-COVID, and which modes will be most promising.

IBT: What changes do you see in the healthcare ecosystem, pre and post-pandemic?

Rupa Chanda: There are many changes, but I think the fundamental shift would be in the comfort level in terms of using digital health. This is one area where I potentially see a big change, both in terms of behavioural change on the demand side, and change in management of the healthcare system via the use of digitalization.

The second, of course, is that people have understood the multisectorality of health with many other verticals, ministries or other stakeholders. For example, look at how the pandemic threw up the importance of supply chains in healthcare, like production of pharmaceutical products, or even simple things like PPE kits.

The third change, I would say, is manpower. While we faced bottlenecks in terms of supply of diagnostics, equipment and vaccines, the importance of adequate and well-trained manpower was realized as well.

It also got us thinking more about the capacity of our own health workforce. We’ve always been aware of it; always known that quality is an issue and it’s very non-uniform across the country. But how do we scale up with quality? The pandemic really made us look at the entire health sector, in a very holistic way. It’s been a rude awakening call in many senses.

IBT: How do you juxtapose this contrast where on one end, we have such deficiencies in manpower, supplies, etc., and yet India is also a leading exporter of medical services?

Rupa Chanda: This has always been a conflict. We talk about exporting manpower and yet, if you look at the WHO’s numbers, India is actually classified as a critical shortage country. So, is the Philippines, which is a big exporter of health manpower.

It’s ironic, of course. India has argued that the way such studies do their threshold calculations for shortage is not correct. If you bring in ASHA workers, the figure is much more in synch with demand.

But clearly, we don’t have to look at the two as ‘one at the expense of the other’. If you want to be an exporter in future, you have to invest in the domestic health workforce, both in scale and quality. I think it is also important to see how you look at many more classes of healthcare workers, and this is also highlighted by the pandemic.

IBT: Please elaborate on the point of more classes of healthcare workers. Also, there is a concern that a lot of workers who travel via Mode 4 tend to settle there.

Rupa Chanda: You don’t have to just talk about traditional exports of nurses and doctors. There are many other categories of healthcare workers, where there are huge opportunities. Many of the allied health professionals or less qualified categories of health workers can explore such opportunities, because of the demographics in other countries. In that case, it will be a win-win in both senses.

Alongside that, what is important is - why are people leaving today? We need to look at that issue. It is not just the usual economic forces. A large part of it is also poor management of health systems, lack of career advancement and opportunities, exposure, training and so on.

And once people go, even if they just go temporarily, they don’t come back and find those opportunities. The skills they’ve acquired are not given value so that they may be absorbed back into the system. So, there are larger things that we have to look into in terms of human resource management

practices and the development of our workforce.

IBT: India is often seen as the final frontier for medical tourism. Is India looking at a huge opportunity in this arena and what should it be doing to achieve it?

Rupa Chanda: There is an opportunity, but when you ask big hospitals and so on, do they really gear up for medical tourism? They have dedicated super wards for foreign patients. But because the domestic market is so large, affluence levels are rising, and insurance coverage is also gradually picking up, more people can afford this kind of super specialty care.

Actually, their focus is not on the foreign patient. India is not the go-to-place necessarily, for medical tourism from across the world. It is there for South Asia, but even there, we have competition.

India used to be an attractive option for the Middle East, but the latter itself is becoming a medical tourism hub. And since they have affluence, they can afford treatment in other countries.

And the differential in terms of fees is not going to make such a huge difference, unless there are large numbers. So, it’s an opportunity but it will never be the big thing for India’s medical exports. Mode 4 is bigger but not in the traditional sense. Most people go and settle there, so it’s not Mode 4 ultimately.

In fact, Mode 2 is a bigger opportunity, but it has not grown to the extent people think. Mode 2 comes with its own complications too. This is because most of it will be out-of-pocket paying patients, but if you really want to scale this up and get the big ticket, then it’s the insurance part that you have to get. So there’ll be issues of crossborder liability and recognition. Unless you have mutual recognition and insurance providers recognise treatments, they will not be covered.

Then there are issues in always believe that unless you do the domestic capacity building, there is no basis for you to be doing exports. It will happen only in an adhoc way. So, yes, if we put more focus, especially after COVID, on the entire tele-health mission nationally and leverage some of the infrastructure created in recent years, I think it is a possibility.

With cross-border tele-health, again you have regulatory issues, because unless you have mutual recognition, a doctor’s diagnosis from here will not be validated there. So, basically the person will be given a ghost diagnosis and over there, someone else will have to read the document and sign off on it. So, you need another certification. Thus, it comes back to recognition of qualifications.

This basically means that if you want to export more health, you have to have complementary issues addressed on the legal, insurance and logistics side. It comes back to creating that ecosystem overall.

IBT: Among the modes, which one is the most promising for India, at present?

Rupa Chanda: After COVID-19, if alternatives really were to pick up in a big way, people have become much more aware of wellness and alternative therapies. If India could really put a big push on it, and this is not an area that gets covered normally anyway, by insurance, it’s a certain class of patients. This is an opportunity, I think, where we have a niche. However, medical tourism after COVID-19 is also a challenge, because of the way travel restrictions come into play. But alternatives is a niche within the medical field.

India has an opportunity to address many of the challenges in Modes 1, 2 & 4, if it could do more of Mode 3 exports. Once you set up establishments, maybe partly locally employed, you create hubs in other places, which you then use. Of course, it’s not your direct Mode 2 export, but it actually can have a lot of spinoffs in terms of bringing patients from there.

many countries like flying time restrictions. So, if you want to tap a particular market, you will not be able to do so, until you can get into G2G arrangements, and accredit certain institutions, where people come for various procedures.

IBT: How can we make India a more attractive medical tourism destination?

Rupa Chanda: Medical tourism goes a lot with perception. Firstly, I think the perception of India as a safe, clean, tourist-friendly place has to be there. When I did my surveys, I found that this general perception is missing. The cost difference is large, but still, sometimes people choose not to come here, just because it’s not seen as an easy country to come and do your treatment compared to many others. A lot of related facilities such as tourist visas for visitors, etc, have to be improved.

Thus, we need to be more strategic in terms of target markets and look at particular barriers affecting the flow of patients from these countries. Maybe we can have some sort of referral arrangements – private establishments are already doing so. Some incentives or benefits are required from the government’s side to give this more of a push.

IBT: Can Digital India initiatives ramp up capabilities or overcome the barriers of infrastructure?

Rupa Chanda: Digital health exports is always a possibility, but again, the first and foremost pre-requisite is infrastructure. I