International patients with congenital heart disease: what brings them to India?

Abstract

Background

Factors that have led to the increasing popularity of medical travel include the high cost of healthcare, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.

Aim

The present study aims to elaborate the factors that attract international cardiac patients to India, to document the proportion of the admissions into the paediatric cardiac ward who are international patients, and to identify the sources of funding of the international patients.

Methods

This was a prospective, cross-sectional, and analytical study carried out between May 2009 and October 2009 in the paediatric cardiac care unit of a large tertiary care cardiac centre in India paediatric wards. Structured questionnaires were administered.

Results

A total of 1372 patients were admitted during the study period, of which 155 (11.3%) were patients from countries outside India. Majority of the patients were from Malaysia (45%), Nigeria (23%), and Tanzania (15%). The age ranged from 1 month to 39 years with an average of 61 months. The male to female ratio was 1:1.4 and the majority of subjects (72.5%) were in social classes 3 and 4. cheaper cost and better expertise was the prominent reason for choosing India. More than half of the respondents were either sponsored by the government or self-funded. For patients from Nigeria 53% (9) were sponsored by self (parent), 29% (5) by non-governmental organisations (NGO), 12% (2) by the parent employer, and 6% (1) by the government.

Conclusion

There is a need for local development of facilities and training of personnel in specialised areas of healthcare to provide succour for a significant number of nationals who might otherwise have suffered and possibly have even died of their ailment. There is also the added advantage that such facilities would save foreign currency and help boost our economy.

Introduction

Medical tourism can be broadly defined as a provision of ‘cost-effective’ private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialised treatment. This process is being facilitated both by the corporate sector involved in medical care as well as by the tourism industry—both private and public.¹

The concept of medical tourism is not new. The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims travelled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism. Spa towns and sanitariums may also be considered an early form of medical tourism. In the 18th century in England, patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.²

Factors that have led to the increasing popularity of medical travel include the high cost of healthcare, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.³

Over 50 countries have identified medical tourism as a national industry.² The countries where medical tourism is being actively promoted include Greece, South Africa, Jordan, India, Malaysia, Philippines, and Singapore. Although India is a recent entrant into medical tourism, the Indian government predicts that India's $17-billion-a-year healthcare industry could grow 13% in each of the next 6 years, boosted by medical tourism, which industry watchers say is growing at 30% annually. Price advantage is a major selling point. Thus the slogan, ‘First World Treatment at Third World Prices’. The cost differential across the board is huge; only a 10th and sometimes even a 16th of the cost in the West. India has a lot of hospitals offering world class treatments in nearly every medical sector.¹

Not only is India one of the world's oldest medical tourism destinations where global tourists have traditionally come for Ayurveda and other therapies, but it has also now become one of the world's most popular medical tourism spot.¹

The Indian healthcare market is 15 billion and growing at over 30% every year. Indian private hospitals are increasingly finding a mention in the travel itineraries of foreigners, with the trend of medical tourism catching up in the country. If industry estimates are to be believed, the size of the medical tourism industry stands at 200–1500 crore (12–15 billion). A recent CII-McKinsey study on Indian healthcare states that medical tourism alone can contribute 5000–10,000 crore (50–100 billion) additional revenue for tertiary hospitals by 2012, and will account for 3–5% of the total healthcare delivery market.¹ This is a huge, untapped market, not just for therapeutic medical tourism like Ayurveda, but also for curative treatment. India can lead the world in medical and health tourism, since we have a tremendous advantage with a large pool of skilled manpower and technological edge.¹

Our study attempted to analyse the reasons why patients outside of India seek cardiac care, especially paediatric cardiac care, within India.

Objectives

The present study aims:

• 1.To study the factors that attract international cardiac patients to India;
• 2.To document the proportion of the admissions of international patients into the paediatric cardiac ward;
• 3.To identify the sources of funding of the international patients.

Materials and methods

This was a prospective, cross-sectional and analytical study carried out between May 2009 and October 2009 in the Paediatric Cardiac care unit of a large tertiary care cardiac centre in India. The subjects were international patients admitted into the paediatric wards.

Ethical clearance for the study was obtained from the Ethics Committee of the Hospital and informed consent was sought from parents or caregivers of potential subjects before enrolment into the study.

Structured questionnaires were administered to consecutive parents or caregivers of the patients after the aim of the study was explained to them. The questionnaires were filled by the participants and returned immediately. Patients whose caregivers were not willing to fill the questionnaire were excluded from the study.

Social class classification was performed according to Oyedeji.⁴ The data was analysed using Microsoft Excel Program.

Results

A total of 1372 patients were admitted during the study period, of which 155 (11.3%) were patients from countries outside India. Of these, 72 questionnaires were either not appropriately filled or incompletely filled. Hence, a total of 73 questionnaires were analysed and the study group was formed.

The general characteristics of subjects and controls including country of origin, age, gender, and social class distributions are shown in Table 1. Majority of the patients were from Malaysia (45%), Nigeria (23%), and Tanzania (15%). The age ranged from 1 month to 39 years with an average of 61 months. The male to female ratio was 1:1.4 and the majority of subjects (72.5%) were in social classes 3 and 4.

Table 1.

General characteristics of study subjects.

	Number of subjects (%)
Country
Malaysia	33 (45)
Nigeria	17 (23)
Tanzania	11 (15)
Bangladesh	8 (11)
Oman	2 (3)
Pakistan	1 (1.4)
Maldives	1 (1.4)
Age (mo)
<6	4 (5.4)
6–12	12 (16.4)
>12–23	16 (22.0)
24–59	23 (31.5)
60–120	10 (13.7)
>120	8 (10.9)
Gender
Male	30 (41)
Female	43 (59)
Social class distribution of the subjects
Social class
1	1 (1.4)
2	8 (10.9)
3	31 (42.5)
4	22 (30.1)
5	11 (15.1)

Table 2 shows that the majority of the patients were referred by their local doctor while Table 3 shows sources of funding of the respondents. More than half of the respondents were either sponsored by the government or self-funded. For patients from Nigeria, 53% (9) were sponsored by self (parent), 29% (5) by non-governmental organisations (NGO), 12% (2) by the parent employer, and 6% (1) by the government. Table 4 shows the number of respondents with regrets versus those that will recommend the Indian Hospital to others. Up to one-quarter of the respondents expressed regret and would not recommend India to their colleagues. However, two-thirds would still recommend the Indian Hospital to others for treatment.

Table 2.

Introduction to Indian Hospital.

Means of introduction	Number of patients (%)
Non-government organisation	10 (13.7)
Local doctor	52 (71.2)
Friends	10 (13.7)
Internet	1 (1.4)

Table 3.

Sources of funding.

Source	Number of subjects (%)
Self	19 (26)
Employer	2 (2.7)
Loan	5 (6.8)
Government	41 (56.2)
Self and loan	1 (1.4)
Non-government organisation	7 (9.6)

Table 4.

Number of respondents with regrets versus those that will recommend the Indian Hospital to others.

	With regret n (%)	No regret n (%)
Will recommend Indian Hospital	13 (72)	52 (94)
Will not recommend Indian Hospital	5 (28)	3 (6)
Total	18 (100)	55 (100)

Figures 1 and 2 show the availability of comparable healthcare services in respondent's country of origin and their awareness of alternative countries where comparable medical services is obtainable. More than 50% of the respondents have comparable healthcare services in their country of origin; these were mostly subjects from Malaysia while >70% are aware of alternatives.

Figure 1.

Availability of comparable healthcare services in countries of origin.

Figure 2.

Awareness of alternative countries where comparable medical services is obtainable.

Figure 3 shows reasons why India was chosen for treatment among those with alternatives and without alternatives. In both categories cheaper cost and better expertise was the prominent reason for choosing India.

Figure 3.

Reason for choosing India among those with alternatives and those without alternatives.

Figure 4 shows average cost of transportation of respondents to India. More than 70% of the respondents spent >1000 dollars on transportation.

Figure 4.

Average cost of transportation of respondents to India in dollars.

More than 90% wanted the same facility in their country while up to one-fifth of the respondents would still prefer to come to India even if the facility is available in their country. However, up to 29% of this group will still prefer to travel to India for their surgery even if the facility is available in their country.

Discussion

The present study was designed to determine why international patients travel to India to obtain their cardiac treatment. Our study revealed that one of every 10 of the paediatric cardiac admissions at a major cardiac centre in India were international patients. This confirms the position of India among countries commonly visited in search of high quality specialised treatment.

Almost half of the international patients did not participate in the study principally because they could not communicate in English. The study shows that up to 45% of the international patients were from Malaysia. This is surprising since comparable medical and surgical treatments are also available in that country, and Malaysia is actually one of the countries known for medical tourism. The Malaysians may be in India for treatment due to various other reasons. There was a claim of delays in intervention as a result of long waiting lists and also the paucity of centres equipped for provision of paediatric cardiac surgery. Added to the physical proximity to India and therefore to the relatively low transportation cost, the decision to go to India may not have been too difficult.

On the other hand, the percentage of respondents from Africa (38%) should be considered high because unlike Malaysia, Africa is geographically and culturally far from India. However, there were other more compelling factors in operation. These include the non-availability of similar specialised care in the home country and a relative cost advantage over the other advanced countries such as Europe and America. For a procedure like repair of a ventricular septal defect for instance, the cost of travel, surgery, and a 3-week stay in India would cost around $7500. This is just about 10% of an estimated cost of open heart surgery in the United Kingdom.

There is also the ‘bandwagon’ effect. This was generated by the first few successful visits after which going to India for cardiac surgery has increasingly become a viable option. The influence of the ‘bandwagon’ effect also extends to the medical practitioners themselves in as much as the Indian option was introduced to the patients by their primary physician in a high percentage of cases.

A high proportion of the patients were sponsored by the government, which included all the patients from Malaysia and a few African patients. This was remarkable as it suggests the approval of the Malaysian government to seek treatment in another country despite its local availability. The reason for this is not immediately clear but may corroborate claims of delays in treatment as a result of long waiting lists in the home country and of the relative lack of facilities for paediatric cardiac surgery.

This study also demonstrated that >90% of the respondents desire a similar, affordable, and available standard of care in their country of origin. More importantly, the majority of them would not have chosen to go to India if they had competent services in their own home country. It must be understood that the respondents are among the few who either could afford to go to India on their own or who were fortunate to receive sponsorship. The vast majority who are not quite as fortunate are left at home perhaps to die from their conditions. For example, over a period of 2 years, in the institution of one of the authors (BAA) only 8% (20 of the 250 patients) of the patients diagnosed with congenital heart disease necessitating surgery have been able to visit India for intervention. Thus, there can be no alternative to local development of facilities and training of personnel in specialised areas of healthcare. It is true that the investments in establishing such a centre are enormous and possibly beyond the reach of some resource-challenged countries. The rewards are, however, almost incalculable in terms of providing succour for a significant number of nationals who might otherwise have suffered and possibly even have died of their ailment. There is also the added advantage that the country with such facilities would not only save foreign currency which might otherwise have been consumed, but also benefit immensely from medical tourism and be in a position to improve services even further. These rewards should be the focus for a country like Nigeria endowed with so much natural resources and with nationals who are excelling in specialised areas of healthcare all over the world.

Beside the problem of high medical costs, there are other groups of patients who cannot wait for India. These include babies requiring emergency attention soon after birth and patients who may be too ill to be accepted by regular airlines. Local development of facilities will certainly benefit such patients.