November 20, 2017
World Market

Healthcare

Offshore healthcare management: medical tourism between Kenya, Tanzania and India

Author : Renu Modi
Ref : India- Africa Book
Volume Edited By : Emma Mawdsley and Gerard Mccain
For more information, please visit : http://fahamubooks.org/book/?GCOI=90638100776420

 

Introduction

The term medical tourism is used in common parlance to describe the phenomenon of foreign patients seeking healthcare in another country at better equipped hospitals and/or at rates comparatively cheaper than in their home countries. India has been a destination country for some time. For example, the Chennai-based Apollo group of hospitals was one of the first to receive international patients, mainly people from the United Kingdom seeking cataract surgery in the early 1990s at a time when the British healthcare sector was under pressure because of funding and staff constraints. The inflow from the UK was followed by individuals from other European countries, the United States, Middle East, South East Asia, and later from the African continent. A particularly strong demand comes from the 20 million strong Indian diaspora scattered across the globe.

This chapter deals with medical tourism from Africa, specifically from Kenya and Tanzania, to Indian hospitals particularly in the city of Mumbai. It also comments on the growing relationship emerging between private healthcare providers in India and East Africa, as well as Indian government support for health initiatives. We can understand this evolving industry in the current context of globalisation and liberalisation, which has impacted on all the sectors of the Indian economy.

India is emerging as a global healthcare provider because of its ability to offer world-class expertise at developing world costs. There has been a proliferation of new healthcare facilities at private centres of medical excellence in Mumbai specifically. Highclass medical infrastructure facilities, coupled with improved and cheaper air connections and easy access to visa facilities, are some of the factors that have contributed to the emerging scenario.

Methodology

This chapter is based on primary and secondary sources. The primary data are derived from interviews conducted with 52 African patients admitted to various hospitals in Mumbai between March and June 2008. Of these only four patients were of Asian origin, while 48 were black Africans-41 from the East African countries of Kenya and Tanzania. The rest were from Ghana, Burundi and Democratic Republic of Congo (DRC). In this sample, 35 were men, seven were children below the age of 18 and 10 were women.

This research focused on black Africans because they were easily identified as Africans by the hospital staff. The researcher was informed that several Asian-Africans, mainly Gujaratis, went for treatment to the hospitals in Ahmadabad and other cities in Gujarat because they had family members there.

Interviews were conducted among African patients in four leading hospitals in the city, namely the Hinduja Medical Research Centre, Wockhardt Hospital, Prince Aly Khan Hospital, and the Asian Heart Research Institute. African medical tourists also visit other hospitals in the city such as Jaslok, Tata Memorial, Saifee and Breach Candy Hospitals in addition to smaller private clinics and diagnostic centres. The author also made enquiries at several leading dental clinics, cosmetologists and spas, Ayurvedic centres and yoga institutes in the city and was informed that most of the clientele for dental treatment, body contouring, liposuction and stress management were from Europe, North America and the Middle East.

It became clear that the majority of the African patients (including patients of Indian origin) seek treatment in India for mainly medical ailments that have not been diagnosed accurately in their country of origin or for severe medical conditions, for which locally there is inadequate expertise and lack of high technology facilities.

Information was gathered through semi-structured interviews to explore the pattern of flows of African patients to Indian hospitals, namely their countries of origin, reason for seeking medical treatment, the system of referrals, the success rate/satisfaction of treatment, the costs involved, how they raised funds for treatment and the system insurance cover. Interviews were also conducted in Africa with 12 patients from Kenya and Tanzania who had returned and were willing to share information about the followup mechanism of check ups and investigations once back in their home countries.

I faced several constraints in the course of the interviews as would be expected when dealing with patients who are seriously ill. These included ethical concerns about interviewing vulnerable people, the busy and erratic schedules of doctors and caregivers, or their unwillingness to talk about this issue. I also tried to get access to data on the number of African patients disembarking at Mumbai international airport with a medical visa. However, the customs officials were reluctant to provide this information and also stated that there was an absence of country-wide disaggregated data on Africans as such or for those coming in for medical treatment.

Another problematic issue was the term medical tourism, which was not familiar to a number of respondents. They tended to interpret it literally and were initially puzzled by (and disapproving of) its use. 'Tourism in the conventional sense conveys fun, sightseeing and holiday. Chemotherapy in India is certainly not my idea of tourism', stated a senior oncologist at a hospital in Mumbai. For this reason, the author stopped using the term in interviews, and referred instead to 'offshore health management'. Since there is relatively little published secondary literature available on this specific subject, the author relied on other sources, such as newspaper articles in leading Tanzanian and Kenyan dailies, and online resources such as Pambazuka News, World Bank development reports and websites of the ministries of health in Kenya and Tanzania or the African Union.

The paper is divided into three main parts. The first deals with the health contexts of Kenya and Tanzania. The second analyses the Indian context and the reasons why it is a preferred destination for many African patients. The third, concluding section highlights the efforts taken on the continent to improve the state of public health delivery and augment existing medical facilities.

Private and public health provision in Tanzania and Kenya

The two East African countries of Kenya and Tanzania have a population of 37.5 million and 40.4 million respectively (World Bank 2008a, 2008b). Healthcare is organised in a pyramid structure in both countries, with government-run dispensaries forming the broad base of the medical system and comprising the first point of contact, principally for simple ailments. At the higher levels of public provision there are health centres, sub-district hospitals and provincial hospitals, which are referral points for district hospitals. The more complicated cases are sent to the national referral hospitals. Alongside this formal system is a substantial system of 'traditional' healthcare.

Healthcare in these two neighbouring countries has in theory laid emphasis on primary healthcare at affordable rates, making them pioneers in sub-Saharan Africa. The distribution of health facilities has a heavy rural emphasis because more than 70 per cent of the population lives in rural areas. Plans for the establishment of health facilities have in the past taken into consideration the facility/population ratio, but with time this has in some areas been seriously overtaken by the high population growth rate. Moreover, good medical care is not within the reach of the majority of the least developed countries such as Kenya and Tanzania where governments with considerable budgetary constraints have been the principal providers of both preventive and curative treatment.

Public health delivery in Africa in general is lacking in affordability, accessibility and quality. It is marred by limited human resource capacity and is understaffed in the face of many pressing health issues, including the HIV/AIDS epidemic. In many places the personnel shortage is worsened by the flow of health professionals to richer countries in search of better salaries and working conditions. Public provision is also beset with problems of poor management and corruption. The underfinanced medical health delivery system, in which there is a wide chasm between needs and the resource pool, has worsened in the wake of the current credit crunch.

The healthcare system in most African countries, including Kenya and Tanzania, was hit hard by the 'structural adjustment' policies introduced and imposed by the International Monetary Fund and the World Bank in the 1980s. Their insistence on low inflation rates and cuts in wage and budgetary expenditure in borrowing countries have proved detrimental to social sectors like health, with particularly damaging impacts for the poor. Hospitals often work under highly unfavourable conditions, especially the public hospitals which lack the basic infrastructure for healthcare. There is little access to healthcare because the poor, who form a sizeable section of the population, are unable to pay either the user fees or the transport costs.

The problem is compounded by the fact that the continent is heavily dependent on imported pharmaceutical products that lead to the high cost of medicine. The vagaries of transportation at times results in the withdrawal of medicines, including life-saving drugs, from the market. Traditional healers and birth attendants continue to be important providers of health services, especially in rural areas and poorer urban areas, such as Kibera in Nairobi.

According to the World Bank sources and based on household budget surveys, 36 per cent of the population of Tanzania lives below the national poverty line, and life expectancy at birth in Tanzania is only 52 years (World Bank 2008b). Total government expenditure on health as a percentage of gross domestic product in 2006 was 6.4 per cent whereas private expenditure on health as percentage of total expenditure on health in the same year was 42.2 per cent. External resources as a percentage of total expenditure on health comprised 27.8 per cent in 2006. In the following year the total government expenditure on health as a percentage of gross domestic product fell to 5.3 per cent while the corresponding data for external resources as a percentage of total expenditure on health rose to 49.9 per cent (World Health Organisation 2010, p. 136).

The Kenyan Household Budget Survey indicates that absolute poverty declined from 52.3 per cent in 1997 to 46.1 per cent in 2005/06, which is still very high compared to Tanzania and neighbouring Uganda (about 31 per cent). The average life expectancy is about 54 years. In 2005/06, of the total population of 36 million, 16.7 million were below the poverty line. The central government expenditure on health as a percentage of gross domestic product in 2005 was only 4.6 per cent (World Bank 2009). We discuss now in more detail healthcare in both Tanzania and Kenya.

Tanzania

During the colonial era, the private providers of health services included non-government organisations - mainly religious organisations and the voluntary agencies - as well as various state health institutions, often explicitly or tacitly defining clientele according to racial demarcations. The religious organisations were and are categorised as 'private not for profit' providers of health services.

Following independence, healthcare was considered to be more definitively a domain of the state, yet a limited number of private facilities were provided in major towns of the country. But in 1975 the government of Tanzania nationalised all the hospitals including those run by the Christian Missions and in 1977 'private health service for profit' was banned under the Private Hospital (Regulation) Act. The practice of medicine and dentistry as a commercial service was also prohibited. Julius Nyerere believed that human health should not be a commodity to be exploited. However, this act had a negative impact on the delivery of health services because it led to the roll back of the private sector and resulted in the shrinking of the supply of medical services (Government of Tanzania 2002/03). About a decade and a half later the government again recognised the role of the private sector in healthcare. The law was amended with the Private Hospitals (Regulation) Amendment Act 1991, whereby qualified medical practitioners and dentists could run private hospitals with the permission of the Ministry of Health.

The phenomenon of medical tourism from Tanzania is not new. More affluent patients have been going abroad for treatment or have been treated by foreign doctors since the early 1980s. A doctor at a hospital in Dar es Salaam drew an analogy of African medical tourists to India as 'unhealthy refugees' who had to flee their own borders to seek medical treatment in other parts of the world. I was informed that in 1983, Dr Rajani Kanabar, a medical practitioner and director of Regency Medical Centre, a leading private hospital in Tanzania, had facilitated a private team of heart surgeons to come to Dar es Salaam and conduct 50 heart surgeries with the support of the Round Table Association, an international philanthropic organisation. He also organised surgeries for Tanzanian children with congenital heart disease at the Metropolitan Medical Centre at Minneapolis in the USA in the 1980s through the Lions International and the Tanzania Heart Foundation. Dr Kanabar made efforts to get treatment for Tanzanians in India as well. Since 1986, 50 children have been sent to Mumbai through the sponsorship of the Lions Club, Dar es Salaam and the Ministry of Health in Tanzania.

Over the past few years about 1,000 Tanzanian patients have sought treatment at the Apollo Hospital in Hyderabad, the Madras Medical Mission in Chennai, and the Narayan Hrudalayalaya Heart Institute in Bangalore, under the guidance of the internationally reputed heart surgeons, such as Dr Devi Shetty and Dr K.M. Cherian, and at a discounted price of rupees 1,650 (a fee that includes boarding and lodging).

The former president of India, Dr Abdul Kalam, in his capacity as patron of the Care Hospital in Hyderabad, donated ten free heart surgeries for Tanzanian patients. He also offered cardiac surgery training for government doctors, who were to be identified through the Tanzania Ministry of Health at the same hospital. Over the past three decades about 2,000 heart surgeries have been facilitated in Indian hospitals because of the international quality medical standards and near 100 per cent success rate (about 99 per cent) at one-third the cost of similar surgery in developed nations. Tanzanians have also been sent to Manipal hospital in the state of Karnataka, for treatment of kidney ailments and dialysis, given the lack of a kidney treatment centre in their country.

Although India is able to provide relatively affordable medical treatment, this is still something only affluent Africans can afford, leaving the vast majority of the population under-served. In Tanzania every year more than 7,000 children with congenital heart disease and adolescents with rheumatic heart diseases await open-heart surgery treatment. In an interview, Dr Kanabar described the financial assistance he had sought through various international communities and charities to import state-of-the-art medical and surgical facilities that are currently unavailable in Tanzania. Even so, these would still be within the private sector and thus inaccessible to the poor, except through occasional charitable cases.

Through Dr Kanabar's efforts, Dr Kiran and Dr Pallavi Patel of Global Understanding Foundation, a US charity, visited Tanzania in July 2005 and pledged their support and equipment of up to $2 million. The government of Tanzania has promised a land grant, the Lions Club International has agreed to bear the cost of infrastructure and Narayan Hrudalaya, Bangalore, will send in a core team.

So it seems likely that Tanzania will soon have a medical centre for heart patients. A Tanzanian newspaper reported that heart examinations would be done free of cost in Dar es Salaam and Zanzibar under the auspices of the Lions Club and their chairperson, Dr Kanabar. It also reported that Narayan Hrudalaya would conduct 50 heart surgeries at reduced rates through 2007 and 2008 (Mwendapole 2007).

Treatment in private Tanzanian hospitals such as Regency Medical or Aga Khan Hospital is expensive. But patients often have no alternative as these are the better equipped hospitals. The other hospitals, such as the Hindu Mandal (founded in 1918 as part of a local sociocultural association thanks to donations from Indian trusts and individuals) are only relatively cheaper, hence the costs of treatment are still unaffordable for many patients.

The Indian doctors who visit Tanzania establish their initial point of contact between the patient and the doctor through their local consultants. The patients get information about the visits of the Indian doctors ahead of time and the dates and venues of their consultations are advertised on the Indian television channels in Dar es Salaam and in local newspapers. Those diagnosed with complicated aliments that need advanced treatment are advised by the visiting Indian doctor to travel to India for treatment.

Kenya

In Kenya too, the medical situation is critical, with insufficient doctors, nurses and other trained providers available to run basic health services, compounding problems of severely constrained funding. Following the doctor's strike of 1994, many medical personnel in the country left for better pay packages in South Africa, Botswana, Lesotho and Swaziland. Nurses also emigrated to the United Kingdom. An October 2005 communication from an NGO coalition to the November 2005 High Level Forum on Health Millennium Development Goals noted that between 1991 and 2003, the Kenyan government reduced its work force by 30 per cent-cuts that hit the health sector particularly hard. For the period between 2000 and 2002 alone, the government was scheduled to lay off 5,300 health staff. Those conditionalities were externally imposed by the International Monetary Fund (IMF) and World Bank in the 1980s as a part of their structural adjustment programme. As a consequence, local health clinics and dispensaries had fewer supplies and medicines and user fees became more common.

The public hospitals saw their standard of care deteriorate, increasing pressure on the largest public facility, the Kenyatta National Hospital in Nairobi. The hospital, once the leading health facility in East Africa, withdrew subsidies and requested patients' families provide food, medicine and medical supplies. Professional staff members have taken jobs (some part time, some full time) at private healthcare facilities, or have migrated to Europe or North America in search of better pay (Ambrose 2006). The costs of treatments are high in private hospitals. Those who are critically ill and can mobilise resources opt to travel abroad to countries like India for treatment.

India as a destination for medical tourism

African patients of Indian origin have been coming to India for several years, but black Africans from Burundi, Côte d'Ivoire, DRC, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Tanzania and Zambia have been accessing treatment since the late 1990s. African patients can access quality treatment at internationally accredited Indian hospitals. The 20-million strong Indian diaspora in general, and especially the Gujarati clientele of Indian origin in East Africa, who have roots and established connections on both sides of the Indian Ocean, have come to India for treatment, as stated, but have also helped in the building of 'brand India' through good publicity for potential patients from Africa.

There is no organised manner of referrals for potential patients who seek treatment in India. Patients come mainly through word of mouth, for example through their relatives who have had a satisfactory experience in Indian hospitals. The initial contact with Indian doctors is established through referrals by their local consultants (African doctors meet Indian doctors at medical conferences in various parts of the world) or through initial contact with Indian medical practitioners who visit Africa through local religious, philanthropic organisations such as the Lions or Rotary International or through private hospitals.

Doctors in India also approach prospective patients in Africa through associations of general practitioners in various African countries. Some hospitals, such as Prince Aly Khan Hospital in Mumbai, one of the Aga Khan group of hospitals, regularly send their teams to Tanzania and Kenya to set up initial contact with patients through medical centres such as Regency Hospital in Dar es Salaam and the Aga Khan hospitals in Tanzania and Kenya. Promotional tours are also conducted by Indian hospitals. In order to promote Apollo as a destination for healthcare, representatives were sent to the ITB Exhibition of travel and tourism held in Berlin in 2003, where it showcased its facilities.

The response was overwhelming and Apollo started an international marketing division soon after. The hospital has now teamed with more than 10 international insurance companies and has its own health insurance company - Apollo DVK - and third party administrators abroad (Medindia 2008). The CEO of Apollo pointed out the attraction of India in that 'a heart surgery works out to rupees two lakhs [about $ 4,350 at current exchange rates] here and it is not a small amount. It is the rupee value that makes healthcare cheaper here' (quoted in Medindia 2008). More recently, in August 2008, a delegation of the Confederation of Indian Industries - a national forum for promoting Indian business - met the Tanzanian president and other high-ranking officials in Tanzania and Madagascar.

Hospital groups are engaged in setting up promotional and relationship-building exercises through established hospitals and individual doctors who are currently travelling to African countries on a personal basis. Some of the Indian hospitals, such as Apollo, Fortis and Wockhardt are now geared to receive international patients and details about the services offered can be accessed through the internet and teleconferences. The appointments with doctors, the dates of surgery, and so on, are fixed prior to their arrival. In Mumbai, the Asian Heart Research Institute and Wockhardt hospitals have oriented toward an international patient clientele with a separate marketing division that facilitates in providing airport pick-ups, accommodation for relatives in nearby hotels, blood collection facilities and lodges where the patients stay during the post-discharge recovery period.

Furthermore, a new category of service providers are the medical tourism facilitators, such as AAREX India, Fire Runner Health Care Consultants, Infotrex Services Private Limited and MedicaltourisminGujarat.com, who contact patients in African countries through the internet and link them to Indian hospitals according to the nature of treatment required, the budget and other preferences. However, some of these brokerage agencies are open to accusations of corruption. The author found that one such facilitator company in Mumbai was owned by the nephew of the leading doctor in Tanzania and it was alleged by other doctors that this nephew-uncle team routed patients to a particular hospital in Mumbai for 'good commissions'.

Response of informants (patients and doctors)

One of the patients the author met in Tanzania had undergone a knee replacement at the Shelby hospital in Gujarat. She stated that doctors from hospitals that include Shelby, Prince Aly Khan in Mumbai, Apollo Hospital in Hyderabad and several others visited Dar es Salaam at regular intervals to establish contact with the patients. Her son then did some background research to reconfirm the costs involved by phone and the internet. He stated that the treatment at Shelby hospital was very expensive but the facilities offered were five-star and allowed him to do his office work through wifi connectivity provided in the hospital room and also attend to his elderly mother undergoing treatment.

Most of the patients were extremely satisfied with the outcome of treatment/surgery in India. Two of them stated that they had suffered so long because of wrong diagnosis in their home countries because the doctors were not so skilled and that they did not have the 'big machines' that they saw in Indian hospitals. They were surprised that every Indian hospital had an MRI machine, which is not the case in Africa. They also stated that they were happy with the extra care and treatment provided by doctors and the attendant staff.

However, three of the patients interviewed stated that they were not happy with the nurses, who they thought were 'not sincere'. Some of them complained about the vegetarian food being served in Indian hospitals as it was too spicy. With regard to the expenses involved, most of them thought that hospitals in India were quite expensive but they were definitely cheaper than hospitals in the West, which in most cases were unaffordable for most of the patients from middle or lower-middle-class backgrounds. For example, knee replacement surgery in the US would cost about $41,000, while in India the costs are about $9,000; a heart bypass would cost $122,000 in the US, but in India it would cost about $10,000 (Medical Tourism Gujarat 2009). Thus, on an average the costs in Indian specialty hospitals are about a quarter the cost of comparable services in the US.

Several patients raised their medical expenses and airfare costs by pooling small contributions from family members. A spouse or an elder child would usually be the caregiver. In the case of some patients, relatives and children working in United States or Britain assisted in efforts to fund treatments. In other cases, friends and members at the local church made small contributions. Very few patients had insurance cover. A doctor in the Aga Khan Hospital in Nairobi, estimated that only between 2 and 3 per cent of the population in Kenya and Tanzania have private health insurance. He said that only the younger, educated, and the middle and upper-middle classes and those with salaried jobs in corporate sector can afford such insurance.

Insurance companies, such as Medex, AAR, the Bank of Tanzania and Bupa are recent entrants into African markets. Four of the 41 East African patients interviewed were covered by their corporate/government/international agency employers and the remainder paid out of their own pockets.

A doctor in Tanzania noted certain issues with the phenomenon of 'medical tourism' in general, and in India specifically. He stated that patients on medical visas were expected to register at the foreigners' registration office, which was time consuming and problematic for the physically infirm. Another doctor stated that the system of referrals abroad was an 'organised racket' but a necessary evil at times because hospitals in Tanzania did not have the required equipment. It is 'pure business', 'a profit making joint venture', with local doctors who referred to Indian hospitals receiving 'high cuts' for the referral to their Indian counterparts. He stated candidly that, at times, the patients go through too many tests, some of which are not essential for the treatment, but were 'good for business'.

Post-recovery follow-up was done through email, by phone or through the local consultant in the patient's home country. This worked well for diseases for which one-off treatment is required and there is no chance of relapse. But for patients who had come for cancer treatment, for example, this system certainly had its limitations. One Kenyan patient, who had been treated at Hinduja Hospital in Mumbai, was admitted to the Aga Khan Hospital in Nairobi soon after his return, and succumbed to the his disease about 10 months thereafter.

The patients and doctors admitted that treatment abroad has its limitations, not least because some ailments require repeated treatment, careful monitoring and a prolonged recovery period, which is not possible with offshore healthcare, given expenses and time demands.

Government support for health cooperation

Beyond 'medical tourism', more recent developments in healthcare relations between India and Africa are noteworthy, particularly the Pan African e-Network, launched on 26 February 2009. The system of telemedicine, based on the use of electronic information communication and technology, shares India's quality healthcare with African counterparts.

Currently the network offers online medical services through teleconsultation, by linking the 12 specialty hospitals in India to practitioners on the African continent. Ethiopia was selected for the e-network pilot project in 2007. Tele-education programmes between Addis Ababa University, Haramaya learning centres, and the Black Lion and Nekempte hospitals in Ethiopia with Care Hospital in Hyderabad were established.

The AU has short-listed three leading regional universities and two regional hospitals for participation in the e-network. These include Makerere University in Uganda, Kwame Nkrumah University of Science and Technology in Ghana, the University of Yaounde in Cameroon, Ibadan Hospital in Nigeria, and the Brazzaville Hospital in the Republic of Congo.

As a part of the telemedicine project, live consultation is being offered for one hour every day to each of the 53 member's states of the AU in 18 medical disciplines, ranging from cardiology, neurology and urology to gynaecology, infectious diseases, ophthalmology and paediatrics. Furthermore, offline consultation for five patients per day from selected hospitals has been provided. The project also offers skill upgrading through the sharing of information with medical personnel in African countries through its continuing medical education (CME) programme. It is however at a nascent stage and the care offered through telemedicine can be limited for surgical treatment and complicated cases that require state-of-the-art technology. There remains an urgent need to build sustainable heath delivery systems on the continent.

Conclusion

The thriving medical tourism industry and the various business ties and investment opportunities emerging between India and Africa provide the possibility of affordable, high-quality healthcare for those who can afford to pay for treatment abroad. In the years to come, the expanding footprints of the Indian hospitals in various parts of Africa might result in the reversal of the phenomenon of 'medical tourism' to India. The provision of quality healthcare on home ground would certainly be advantageous for the African patients as they can be in a familiar environment and have access to follow-up treatment as well an extended network of caregivers. But the critical issue is whether African governments negotiate terms of contract such that medical facilities can be accessed by both the rich and the poor.

However, with the highly uneven and donor-driven healthcare policies currently in place, African countries need to develop healthcare solutions for the tens of millions of their inhabitants who cannot afford to travel abroad for healthcare. They need to look at financing the health sector in innovative ways, such as social insurance and affordable local user fees.