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Globalisation of Indian Healthcare Services Acharya Nagarjuna University

182

Chapter 5

ADVANTAGE OF SUPPLY OF SKILLED HEALTH

WORKFORCE GLOBALLY

As a consequence of escalating costs of healthcare and aging populations, in

developed countries, has resulted in an increase in the demand for healthcare services.

The overall trend is associated with major health system restructuring initiatives,

technological advances, and changing social values. Health workforce is central to

advancing health. The health sector, more than any other sector, depends on people to

carry out its mission. In any health care system, it is health workers— professionals,

technicians, and auxiliaries—who determine what services will be offered; when,

where, and to what extent they will be utilized; and as a result, what impact the

services will have on the health status of individuals. The success of health activities

depends largely on the effectiveness and quality with which these resources are

managed.

The number of people aged 65 and over will double as a proportion of the

global population, from 7% in 2000 to 16% in 2050. By then, there will be older

people than children (aged 0–14 years) in the population for the first time in human

history.

Chart 1

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Source: Population Division of the Department of Economic and Social Affairs of the United

Nations Secretariat, World Population Prospects: The 2006 Revision and World Urbanization

Prospects: The 2005 Revision, http://esa.un.org/unpp

Scientific and technological advances, industrialization, socioeconomic

development, improved communication, better hygiene and increased food intake have

helped to increase life expectancy and reduce mortality rates in recent decades. Since

1840, global life expectancy has indeed risen in a linear fashion for both sexes, with an

increase of almost three months per year for women. The most dramatic gains have

been in East Asia, and Japan is no exception: it is now the most aged society in the

world. Life expectancy now surpasses 83 years in Japan, the highest level in the world.

Japan also has the highest healthy life expectancy, 78 years for women and 72 years

for men.

Chart 2

Source: Population Division of the Department of Economic and Social Affairs of the United

Nations Secretariat, World Population Prospects: The 2006 Revision and World Urbanization

Prospects: The 2005 Revision, http://esa.un.org/unpp

Changes in the crude death rate reflected a similar trend but in the opposite direction.

Currently, the crude death rate for the entire world is 9.6 per 1,000, but there is

considerable variation amongst nations.

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Chart 3

Source: Population Division of the Department of Economic and Social Affairs of the

United Nations Secretariat, World Population Prospects: The 2006 Revision and

World Urbanization Prospects: The 2005 Revision, http://esa.un.org/unpp

Japan- A society with fewer children

Following a period of rapid growth that started in the late 19th century, Japan’s

population started to slow in the 1980s with an annual pace of growth that averaged

1%. Since the 1980s, this rate has declined sharply with 2005 being the first year of

decrease in the total population.

More than 20 other countries are projected to experience a similar shrinking of

their population in coming decades. In the next five years, citizens over 60 years old

will outnumber children under 5 for the first time globally. In Japan, the elderly have

surpassed the younger age group since 1997. Low fertility rates in many societies,

below that needed to replenish the population, are hastening the demographic

transition occurring worldwide.

More elderly

The immediate consequence of fewer children and more elderly is that the median age

of a society increases. In his 2007 study on ageing in Japan, Florian Coulmas states

that “in 1989, the elderly of 65 years and older accounted for 11.6% of Japanese

population.” In 2006, this proportion had reached 20%, just short of the mark that

indicates the transition from an aged to a hyper-aged society. However, the most

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recent data from the Government of Japan shows that as of March 2008, the number of

people over the age of 65 has reached 21.6%.

Chart 4

Source: United States Census Bureau (2008)

According to Coulmas, there are three different types of society based on the

proportion of elderly as follows:

Ageing society: 7-14% of the population are 65 years or older.

Aged society: 14-21% of the population are 65 years or older.

Hyper-aged society: 21% or more of the population are 65 years or older.

So we can conclude that Japan has now crossed into the “hyper-aged” category.

Perhaps that Population living from outside of Japan can check on the status of their

country and also reflect upon the implications of each phase in the transition to a

hyper-aged society, using Japan’s experience of a guide.

Centenarians are a growing segment of today’s ageing population

More distinctive is the tremendous increase in the oldest old (of which Ms. Yamazaki

is a wonderful example). There are now more than 32,000 centenarians in Japan, 85%

of whom are women. This number has steadily increased since 1970, when there were

only 310 Japanese citizens aged over 100. Between 2005 and 2025, centenarians will

be the age group with the highest increase.

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Chart 5

Source: Ministry of Health, Labour and Welfare (2007).

[http://www.mhlw.go.jp/houdou/2007/09/dl/h0914-3a.pdf]

Japan is the country with the highest number of centenarians, and by 2030, more than

25% of its population is expected to be at least 85 years old.

Developed and Developing Countries travel the same path, at a different pace

Women outlive men in virtually all societies. A few developing countries have higher

male life expectancy than female, but, on average, the female advantage in most

developing countries is slightly less than five years. The gender gap is generally

projected to decrease in developed countries and increase in developing countries.

Ageing affects all societies – high-income as well as low and middle-income

societies – but at a different pace. The same demographic ageing process that unfolded

over 115 years in France, took only 26 years in Japan and will be 21 years in Brazil.

Between 2006 and 2030, the number of older people in low and middle income

countries is projected to increase by 140% as compared to 51% higher income

countries. Demographic changes and ageing are presenting developmental challenges

for many countries, which may grow old before growing rich. WHO report on Social

Development and Ageing – Crisis of Opportunity will pave way for countries like

India to explore the advantage of skilled Healthcare man power. Policy-makers must

be particularly attentive to these challenges and build on successful global

experiences.

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Chart 6

Source: Population Division of the Department of Economic and Social Affairs of the

United Nations Secretariat, World Population Prospects: The 2006 Revision and

World Urbanization Prospects: The 2005 Revision, http://esa.un.org/unpp

India has a population that is growing younger and that will continue to

supply young people to the labor force for a long time145

. Approximately 1/3 of the

world’s population is either Indian or Chinese, but the populations of China and India

are quite different from each other. India’s population is smaller than China’s, but is

growing more rapidly. In 1995, China had nearly 33% more people. By 2005, China

had less than 20% more people. By 2025, their populations will be about equal. After

that, India will have a larger population. Approximately 1/3 of the world’s population

is either Indian or Chinese, but the populations of China and India are quite different

from each other India’s population is smaller than China’s, but is growing more

rapidly. In 1995, China had nearly 33% more people. By 2005, China had less than

20% more people. By 2025, their populations will be about equal. After that, India

will have a larger population. The Indian population with the age group of 20- 46 will

be higher than any country in the world, where Indian Government can take measures

to expand Healthcare Infrastructure, health workforce to meet the demand in Global

market place.

145

“Chindia”:A misleading portfolio concept, January 01, 2008, accessed at:

http://seekingalpha.com/article/58725-chindia-a-misleading-portfolio-concept

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188

Chart 7 Source

146:

http://news.bbc.co.uk/2/shared/spl/hi/guides/456900/456964/html/nn2page1.stm

Here India can take remarkable advantage of supplying young skilled health

work force to other countries. Health workers are not just individuals but integral

parts of functioning health teams in which each member contributes different skills

and performs different functions. Developing capable, motivated and supported health

workers is essential for achievement of national and global health goals. Today, all

countries face health workforce challenges. The types of problems vary across regions

and countries; include shortages, imbalances and low productivity. One of the major

problems for nearly all countries is an overall human resource shortage, which leaves

gaps within the existing infrastructure and services, both within and outside the public

sector. Overall shortages are commonly aggravated by skewed distribution within

countries and movement of health workers from rural to urban areas, from public to

private (for-profit and not-for-profit), or to jobs outside the health sector. Contributing

factors include insufficient investment in pre-service training, migration, work

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BBC News: China & India- Key facts accessed at:

http://news.bbc.co.uk/2/shared/spl/hi/guides/456900/456964/html/nn2page1.stm


189

overload, inadequate growth opportunities and work environment issues

(infrastructure, technical, safety amongst others).

A critical ingredient for building an effective and responsive health system is

the health workforce which includes physicians, nurses, public health workers, policy

makers, administrators, educators, clerical staff, scientists, pharmacists and health

managers amongst others. Today, India is witnessing a growing challenge to maintain

the needed numbers, quality, mix and distribution of personnel to meet the healthcare

needs of the population not only domestic but International. While India is being

propelled to a position of international eminence, it faces three main groups of

challenges: first, dealing effectively with unfinished agendas of communicable

diseases, maternal and child health, and health systems strengthening; second, dealing

with new emerging challenges such as premature burden of non-communicable

diseases; and third, dealing with globalization related issues while contributing to the

management and shaping of the global policy environment. In addressing these

challenges, the health workforce is confronted by shortages, migration, issues of

quality, accountability, public-private coordination, and the complexity of service

provision to large and diverse populations.

India has been producing a lot of young professionals in the fields of medicine,

including specialization in some of the traditional systems. In addition, many

graduates are trained on the job in the travel and tourism industry, which also caters to

the growth of healthcare tourism. The concept of freelancing is also picking up fast in

India, especially in the traditional healthcare segment, where the healthcare

professionals provide their services traveling to various places and offer their services

across the world. As the availability of highly skilled healthcare professionals, and

well-trained travel / tourism professionals are the determinants of growth in healthcare

tourism industry, India is considered as potential land for healthcare tourism business.

The perception of human resources in India depends on the eye of the

beholder: it can appear as a half empty glass or just as equally it can appear half full.


190

Leveraging the country’s existing human resources and planning for tomorrow is an

ongoing challenge.

Who are health workers?-

Human resources actually engaged in the health system can be referred to as the health

system workforce or health workforce– not only physicians and nurses, but also public

health workers, policy makers, educators, clerical staff, scientists and pharmacists.

Together, all these people make up the health workforce.

Current Scenario of Health workforce in India

The state of human resources for health in India is diverse and multifaceted. They

range from rigorously trained biomedical specialists and super-specialists at one end to

an assortment of community and household based healers at the other. One half of this

continuum is studded with trained and qualified doctors of allopathic or modern

biomedicine, psychiatrists, dentists, radiographers, a range of paramedical

Health workers in all

sectors

Health Sector

Professionals

e.g. doctors, nurse

Associates

e.g. laboratory

technician

community e.g. traditional

practitioner

Professionals

e.g. accountant in a hospital

Associates include e.g. administrative professional in a hospital

Support staff and support workers

Health service providers

e.g. clerical workers, drivers in a hospital

Craft and trade workers

All other sectors

Health service providers

e.g. physician

employed in mining

company and other parallel sectors


191

professionals – nurses, pharmacists, laboratory technicians, and a number of allied

personnel – policy makers, health planners and managers, social workers,

psychologists, researchers, health educators and promoters, and health technologists.

While the other half is replete with the richness of India’s traditional healing systems.

Here one finds professionally trained and University qualified practitioners of

Ayurvedic, Unani, Homeopathic, Siddha and Naturopathic medical traditions. One

also comes across informally trained providers through apprenticeships, traditional

and household birth attendants, bone setters, a variety of folk and magico-religious

healers with disease specific specializations, and community or household elders

learned in the art of traditional healing and indigenous remedies.

Private Sector has more contribution in Indian Healthcare and can take the lion

share in catering the needs of domestic and prospective International Medical Tourists.

There are around 1,00,000 plus leading Indian hospitals in delivering Tertiary care in

India as well abroad.

Table 5.1 Centres of Excellence in Healthcare – India

Sl. No. Name of the Hospital Place

Cardiology and Cardiac Surgery

1 All India Institute of Medical Sciences New Delhi

2. Apollo Hospitals Chennai

3. BM Birla Heart Research Institute Calcutta

4. Escorts Heart Institute and Research Centre Delhi

5. Jayadeva Institute of Cardiology Bangalore

6. Krishna Heart Institute Ahmedabad

7. Madras Medical Mission Chennai

8. Manipal Heart Foundation Bangalore

9. Sri Chitra Thirunal Institute of Medical Sciences Thiruvananthapuram

Cancer

10. Apollo Cancer Hospital Chennai

11. Aware Cancer Hospital Hyderabad

12. Dharmashila Cancer Institute Delhi

13. Inlaks and Budhrani Hospital Pune

14. Rajiv Gandhi Cancer Hospital Delhi


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15. Tata Memoria Centre Mumbai

Ophthalmology

16. Aravind Eye Hospital Coimbatore

17. Aravind Eye Hospital Madurai

18. Dr. R. Prasad Institute of Ophthalmic Sciences Delhi

19. LV Prasad Eye Hospital Hyderabad

20. Shankara Deva Nethralaya Guwahati

21. Shankara Nethralaya Chennai

22. Venu Eye Institute Delhi

Orthopaedics

23. Bombay Hospital Mumbai

24. HOSMAT Bangalore

25. Indian Spinal Injuries Centre Delhi

26. Madras Institute for Orthopaedics and Trauma

Neurology, Neurosurgery &

Behaviroural Health

Chennai

27. Indraprastha Apollo Hospital Delhi

28. Manipal Hospital Bangalore

29. NIMHANS Bangalore

30. PD Hinduja National Hospital Mumbai

31. VIMHANS Delhi

Multi Specialty Secondary and Tertiary Care

32. All India Institute of Medical Sciences (AIIMS) Delhi

33. Amrita Institute of Medical Sciences Kochin

34. Apollo Hospitals Chennai

35. Bombay Hospital Mumbai

36. Christian Medical Centre and Hospital Vellore

37. Indraprastha Apollo Hospital Delhi

38. Post-Graduate Institute of Medical Sciences Chandigarh

39. Sri Satya Sai Institute Puttaparthi

Source: The Economic Times

The development of the corporate hospitals is the most important development

in the private health sector in the 80’s.The pioneer in the field was the Apollo


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Hospital in Chennai. And it has set the trend for the others to follow. In fact, it

is the advancement in health care that has shown a big difference in 20 years. In

20 years India has demonstrated this by building more than almost 1000 good

hospitals of international standards in our country.

Table 5.2 Select Corporate hospitals: list of hospitals and their spread147

Hospital

Groups

Number

of

Locations

Number

of

Hospitals

Number

of Beds Coverage

Annual

Revenue

(2005-06

(In Rs.

Crore)

Apollo

Hospital

Enterprise

Ltd

11 11 3000 All Metros 779

Wockhardt

Hospitals 8 10 1400

Bangalore,

Mumbai

and West

India

210

Fortis

Healthcare 5 13 1855 North India 100

Max

Healthcare 1 6 765

Delhi &

NCR 137

Manipal

Health

Systems

9 11 3000

South India

(Mainly

Karnataka)

and Sikkim

-

Care

Hospital 11 14 2000

South and

West India -

Source: indianhealthcare.in

Table 5.3 List of Apollo Hospitals engaged in Tertiary, Secondary and

Primary Health care

Sl.

No.

Name of Owned Hospitals –

Operational

Place Classification

1. Apollo Hospitals Chennai Super Specialty

147

Corporate hospitals: list and number of hospitals and their spread


194

2. Apollo Hospital Hyderabad Super Specialty

3. Apollo Specialty Hospital Chennai Cancer / Neuro /

Ortho

4. Apollo Cancer Hospital Hyderabad Cancer Specialty

5. Apollo Hospitals Madurai Super Specialty

6. Apollo Heart and Kidney Hospital Vizag Cardiac

7. Apollo Hospitals Aragonda Multi Specialty

8. Apollo Hospitals Chennai Multi Specialty

9. Al Khaleej Heart Scan Centre Dubai Diagnostic

10. Apollo Emergency Medical Centre Hyderabad Multi Specialty

11. Apollo Centre Hyderabad Diagnostic

12. Indraprastha Apollo Hospitals New Delhi Super Specialty

13. Apollo (Secondary Care) Hyderabad Secondary Care

14. Apollo (Secondary Care) Hyderabad Secondary Care

Managed Hospitals- Operational

15. Abdur Razzaque Ansari Memorial Ranchi Super Specialty

16. Weavers Hospitals Bihar Tertiary

17. Rajiv Gandhi Cancer Institute New Delhi Cancer Specialty

18. Jahangir Hospital & Medical Centre Pune Multi Specialty

19. Central Travancore Specialists

Hospitals Ltd.,

Chengannur Multi Specialty

20. Saumya Apollo Hospitals Vijayawada Super Specialty

21. Lotus Apollo Hospitals Erode Multi Specialty

22. Jodhana Medical and Research Centre Jodhpur Multi Specialty

23. Nirmay Hospital Dabhol Secondary Care

24. Kirms Apollo Hospitals Nagpur Multi Specialty

25. Amar Hospitals Hyderabad Multi Specialty

26. AMRI Apollo Hospitals Calcutta Multi Specialty

27. Venkatasai Hospitals Ananthapur Multi Specialty

28. NDMC Hospital Bacheli Multi Specialty

29. Florence Medical Centre Siliguri Multi Specialty

Source: The Economic Times, Health Care,


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7

Apollo Hospital Hyderabad Max Hospital Delhi Fortis Hospital, Delhi

Jaslok Hospital, MumbaiBreach Candy Hospital Wokhardt Hospital

Bangalore

Growth of International Standard Hospitals

There is far more to the health workforce in India than meets the eye. To a large extent

this view also depends upon the direction that one is looking from. For the country’s

rural communities, the visible face of human resources might consist mainly of non-

biomedical trained providers while their view of the more-educated and better-

equipped providers may be long distant and blurred. In contrast, the boundaries of

modern clinical medicine often fail to recognize or understand the more traditional

Apollo Hospitals’ Air Ambulance service:

Apollo Hospitals is a pioneer of modern day emergency care in India. It set up the

'National Network of Emergency Services' to provide emergency care of uniform

quality standards across the country. Its 24-hour emergency and trauma care

is geared to meet all medical and surgical emergencies, including polytrauma.

Saving time is the first step in saving lives. Air Ambulance Services are used when

ground transport could endanger a patient's life. They are also indispensable when

the patient is in a remote area and time is critical. Apollo is equipping each of its

hospitals with emergency air ambulance services. The Kolkata and Colombo

hospitals have roof helipads. Their Delhi and Hyderabad hospitals have landing

facilities. Both fixed wing aircrafts and helicopters provide the services. Aviation

companies take care of the aviation logistics. Medical aspects like trained

personnel, equipment and care are provided by the 1066 emergency services.


196

notions of health and the diversity of healers and care providers who do not hold

formal qualifications. Another type of distinction is also possible: the perspective and

requirements of individual users of health resources may differ from the way that the

health system and its gatekeepers view the nation’s needs for a strong health

workforce.

Table: 5.4 State-wise distribution of registered allopathic doctors and dentists

Name of the State

Total

population

% of rural

population

Total doctors

registered with

MCI by 2005

Total

allopathic

Govt.

doctors

registered

Total no.

of doctors

including

specialists

working in

PHCs &

CHC’s

No. of Dentists

1

)

*

Andhra Pradhesh 76210007 72.2 33800 7991 2361 2541

Arunachal Pradesh 1097968 79.2 NA 400 7 8 NA

Assam 26655528 87.1 15927 2103 NA 762

Bihar 82998509 89.5 35111 NA NA 1032

Chhattisgarh 20833803 79.9 318 NA 646 NA

Goa 1347668 50.2 2434 674 60 417

Gujarat 50671017 62.6 37561 2712 940 1453

Haryana 21144564 71.1 1360 2300 911 1648

Himachal Pradesh 6077900 90.2 NA NA 467 469

Jammu & Kashmir 10143700 75.2 8284 1059 785 536

Jharkhand 26945829 77.8 321 1234 NA NA

Karnataka 52850562 66 66574 4100 2732 16058

Kerala 31841374 74 33418 3653 1031 NA

Madhya Pradesh 60348023 73.5 29049 NA 888 1246

Maharashtra 96878627 57.6 92327 5061 4257 10092

Manipur 2166788 73.4 NA 992 86 NA

Meghalaya 2318822 80.4 NA 459 124 NA

Mizoram 888573 50.4 NA NA 251 35

Nagaland 1990036 82.8 NA 293 53 NA

Orissa 36804660 85 14982 4962 1353 307

Punjab 24358999 66.1 34104 3545 599 4159

Rajasthan 56507188 76.6 22666 6235 2087 NA

Sikkim 540851 88.9 NA 181 52 NA NA

Tamil Nadu 62405679 56 72474 8377 2305 5109

Tripura 3199203 82.9 NA 770 154 NA

Uttaranchal 8489349 74.3 NA 1156 253 NA

Uttar Pradesh 166197921 79.2 46251 6766 NA 1763

West Bengal 80176197 72 53129 6022 1452 1539

A & N 356152 67.4 NA 113 36 7

Chandigarh 900635 10.2 NA 1414 4 107

D & N Haveli 220490 77.1 NA 30 8 NA

Daman & Diu 158204 63.8 NA 32 5 NA

Delhi 13850507 6.8 29403 3629 23 1030

Lakshadweep 60650 55.5 NA 22 4 0

Pondicherry 974345 334 NA 389 69 225

Total 1028610 328 72.2 643,520 76925 23858 55344


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Source: GOI, Bulletin on Rural Health Statistics in India, 2006 Accessed from www.

Indiastat.com and Medical Council of India, 2005 accessed from www.indiastat.com

(9 Feb 2007) & Ministry of Heatlh & Family Welfare. accessed from

www.indiastat.com

Table above provides an overview of (a) all MCI registered doctors in different

States of the country, (b) total number of doctors in position in the rural PHCs and

CHCs in the public health system and (c) total number of dentists registered with the

Dental Council. With more than one billion people, India is the second most populous

country in the world accounting for 17% of the world’s population. Subsequently, the

Indian economy grew at a fast rate though concerns on equity and poverty persist. The

country has recently become one of the world’s fastest growing economies with an

average growth rate of over eight percent in last three years.

At the same time, new public health challenges have emerged in the form of

changing demographics and environmental conditions; emerging infectious diseases

and anti-microbial resistance, behavioral issues influencing health and the increasing

focus on non-communicable diseases. Globalization and trade agreements,

technological advances in genetics and medicine, and health informatics hold forth the

potential for more rational, evidence-based management in health care.

Distribution of Healthcare professionals:

India has a pluralistic health sector and health providers. These are distributed across a

professionalized and formally organized health sector and a non-formal health sector.

These human resources can also be categorized into a public sector and a private

sector. Although the health sector is full of many other types of human resources too -

researchers and academics, technologists, social workers, and occupational and

physio-therapists, to name but a few - complete data on these is hard to come by. The

focus of this document is retained on the major categories of health care providers for

whom documentation systems are more in place. In the post independent period, India

witnessed rapid strides in professionalization of biomedical medicine, popularly

known as ‘Allopathy’ as well as in the indigenous systems of Ayurveda, Unani,

Siddha and Homeopathic medicine (AYUSH).


198

Allopathic Doctors

According to most recent figures, there were 643,520 allopathic medical practitioners

practicing in the different states in India and registered with the different State

Councils. Alongside, as on 31st December 2005, about 55000 dental surgeons were

registered with different State Dental Councils. The registered allopathic medical

practitioners include doctors with at least an MBBS degree as well as specialists from

different disciplines. As per the figures available with the MCI, the doctor to

population ratio in India is 1 per 1598 persons or 62.5 doctors per 100,000 population.

The total number of registered doctors (working publicly or privately) varies

considerably across the different states in India, from 1360 in Haryana (approximate

population 21 million) to 92,327 doctors in Maharashtra (approximate population 97

million). The resulting ratios suggest that the number of persons per doctor is less than

1000 for the states of Delhi (1 doctor per 471 persons), Goa (1doctor per 554 persons),

Punjab (1doctor per 714 persons), Karnataka (1 doctor per 794 persons), Tamil Nadu

(1 doctor per 861 persons) and Kerala (1 doctor per 953 persons). Total population

coverage per doctor is highest for the state of Haryana (1:15,547). Figure compares the

situation of total population to total doctors across the states for which data was

considered to be more complete.

Doctors in the private sector

In terms of distribution of providers, over 80% of the qualified private provider market

is concentrated in cities, towns and urban areas. On the basis of an 8 district national

survey, the National Commission on Macroeconomics and Health reported that 75%

of specialists and 85% of technology services were in the private sector (GOI, NCMH,

2005). The same survey also found that 75% of service delivery for dental health,

mental health, orthopedics, vascular and cancer diseases and about 40% of services for

communicable diseases and deliveries were being provided by the private sector. Most

importantly there was a highly skewed rural –urban distribution with a majority of

towns (88%) having a private facility as compared to 24% of rural areas.

Muraleedharan and Nandraj reported a doctor population ratio of 1:860 in the city of


199

Chennai, while the average population coverage per doctor for the whole state of

Tamil Nadu was about 1590. In a study of Ujjain district in Madhya Pradesh, 88% of

the qualified doctors were in urban areas and 72% were practicing in Ujjain city itself

(Deshpande et al, 2004). There was a much higher density of qualified providers in

urban areas (1:2300) than in rural areas (1:26,860). In Kerala, a census of hospitals

showed that about 13 percent of private allopathic medical institutions had just one

physician, and about 42 percent had no more than four physicians (Govt. of Kerala,

1996, cited in Muraleedharan and Nandraj, 2003) Most sole-proprietorship hospitals

employ one or two junior-level physicians and often depend on visiting consultants.

Rural and poor urban dwellings are often served by private providers who do not

possess a recognized qualification or registration (Rohde and Vishwanathan, 1995;

Das and Hammer, 2004; Gautham, 2006). A recent study of mental health services in

the big cities of Delhi, Lucknow and Chennai found that private providers, and non-

formal providers in particular, carried a large portion of the mental health services

load at the primary level in these cities (Desai et al, 2004). Even qualified AYUSH

practitioners are found more in cities and in urban areas than in rural ones.

Growth of Medical Colleges

There was a rapid growth of medical colleges from 25 in 1947 to 106 in 1981 and

more recently, to 260 in 2006 (see table below). Of these 125 colleges are in the public

sector. These are not evenly distributed with the poorer states having a lesser number.

Table No: 5.5 Number of medical colleges during 1980 - 2007

STATE No of Medical colleges

in 1980-81

No of Medical colleges

as on 4th

Dec 2007

Andhra Pradesh 8 32

Assam 3 3

Bihar 9 8

Gujarat 5 13

Haryana 1 3

Himachal Pradesh 1 2

Jammu and Kashmir 2 4

Karnataka 9 36

Kerala 4 18


200

Madhya Pradesh 6 8

Maharashtra 13 39

Orissa 3 4

Punjab 5 7

Rajasthan 5 8

Tamil Nadu 9 25

Uttar Pradesh 9 16

Andhra Pradesh 8 32

Assam 3 3

Bihar 9 8

Gujarat 5 13

West Bengal 7 9

Delhi 4 5

Goa, Daman, Diu 1 1

Pondicherry 1 7

Chandigarh 1 1

Sikkim 0 1

Uttaranchal 0 1

Manipur 0 1

Chattisgarh 0 3

Jharkhand 0 3

Source: For 2007 & for 1981 statistics: GOI, CBHI, Health Statistics in India 1981. New Delhi:

MOHFW. Compiled from www.mciindia.org

However the share of different states in the distribution of medical colleges has

remained uneven While Maharasthra has 13 colleges, Himachal Pradesh has 1 and

Orissa has 3. A medical scholar, D.Banerji, observed “this differential coverage has

wide implications, quite apart from the production of physicians. The attached hospital

of a medical college makes available a high quality of medical care to the local

population. Distribution of medical colleges thus provides an important indicator of

disparities in terms of health institutions and health manpower” (Banerji, 1985).

The number of trained doctors increased from 65,000 in the first plan period to around

300,000 in the sixth plan, and more than 600,000 in 2005. It is estimated that if India

were to meet a hypothetical target of 1 allopathic physician per 1000 population in

2012, the number of students in medical colleges will have to double, and even then,


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more than 300,000 non formal practitioners will have to be involved to provide basic

allopathic treatments (CII-McKinsey & Company, 2002).

The other sibling: AYUSH practitioners

The indigenous systems were revived with the nationalist movement but grew parallel

to the mainstream Western system, and it may even be said, in its shadow. The

concepts of formal institutional training and professional qualifications were not

inherent to the indigenous systems but more a legacy of Western medicine, and these

were adopted by the revivalists to gain recognition for indigenous systems in modern

India. The knowledge of traditional ayurveda, it is known, passed down in families

through an oral learning tradition (Jaggi, 1973). Since the First Plan, allocations were

made for increasing research and education in indigenous systems and Homeopathy.

The growth and education of indigenous systems was guided by their independent

Councils and Acts that regulated practice and education. The Central Council for

Indian Medicine was established in 1971 and the Central Council for Homeopathy in

1974. These Councils formulated standard courses at the undergraduate and

postgraduate levels and also prescribed codes of practice. Similar to western medicine,

a 5-1/2 year University degree became the portal of entry into indigenous medicine as

well. The concepts of formal institutional training and professional qualifications were

not inherent to the indigenous systems but more a legacy of Western medicine, and

these were adopted by the revivalists to gain recognition for indigenous systems in

modern India. The Indian Medicine Central Council Act (1970) and the Homeopathy

Central Council Act (1973) regulates the standards of education and practice in Indian

Systems of Medicine and Homeopathy (WHO, 2007).

As of 2005, there were 717860 qualified AYUSH practitioners registered with their

respective Councils: 438721 Ayurvedic physicians; 43578 Unani physicians; 75601

Siddha practitioners, 217460 Homeopathic practitioners and 541 Naturopathy

practitioners (see Table below). If non-institutionally qualified practitioners are added

to this number, the final tally stands at 717860 (GOI, 2005-06). The states of Bihar

(162383 practitioners), Maharashtra (93663 practitioners) and Uttar Pradesh (100252

practitioners) had the highest numbers of AYUSH practitioners in the country. With


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these counts, Bihar has almost 5 times more AYUSH practitioners than allopathic

physicians and UP has 2.1 times more.

Table 5.6 Number of AYUSH Practitioners

States/UTs Ayurveda Unani Siddha Naturopathy Homoeopathy Total

1 Andhra Pradesh* 15231 5022 0 374 9422 30049

2 Arunachal Pradesh 0 0 0 0 74 74

3 Assam* 250 0 0 0 624 874

4 Bihar* 131121 3665 0 0 27597 162383

5 Chattisgarh 391 4 0 0 139 534

6 Delhi 2264 1049 0 0 2915 6228

7 Gujarat 18029 248 0 0 7517 25794

8 Haryana 19629 1663 0 0 5714 27006

9 Himachal Pradesh 7111 456 0 0 1099 8666

10 J & Kashmir* 343 162 0 0 0 505

11 Karnataka* 14828 938 2 116 7372 23256

12 Kerala 14945 63 1366 0 8871 25245

13 Madhya Pradesh 47602 609 0 2 8781 56994

14 Maharashtra 52372 2884 0 0 38407 93663

15 Meghalaya 0 0 0 0 230 230

16 Nagaland* 0 0 0 0 1997 1997

17 Orissa 4448 17 0 0 3106 7571

18 Punjab* 20379 5611 0 0 7573 33563

19 Rajasthan 23744 1607 0 0 4383 29734

20 Tamil Nadu* 3542 980 16192 49 16902 37665

21 Uttar Pradesh 59569 13666 0 0 27017 100252

22 West Bengal* 2923 4934 0 0 37423 45280

23 Chandigarh* 0 0 0 0 297 297

TOTAL 438721 43578 75601 541 217460 717860

* Information not available for 2005 only, Government of India, Health Report

These alternative practitioners usually practice ambulatory care in solo for-profit

clinics. Practicing more than one system of medicine is quite common (Peters et al,

2002; Gautham, 2006). The AYUSH department also has a network of around 23,000

dispensaries and 1355 hospitals (bed capacity of around 53,000) in the country (GOI,


203

2005-06). So far, coordination between indigenous and allopathic systems of medicine

and between the AYUSH Department and the larger health delivery system has been

limited. Several health policy consultations and recommendations in the last few years

have recognized this gap and recommended that ISM practitioners and systems be

integrated within the health delivery system (GOI, NCMH, 2005; GOI, National

Health Policy, 2002; GOI, Draft National ISM Policy, 2002; GOI, National Rural

Health Mission, 2005).

AYUSH practitioners are roughly equal in numbers to the allopathic medical

practitioners in the country, and in fact even more in some states. Although, like their

allopathic counterparts, alternative practitioners also tend to be concentrated in and

around urban areas, they present a significant resource base for the future of health

systems and improved health outcomes in India. Presently, the Department of

AYUSH, examines issues relating to education, research and regulation. It seeks to

upgrade the educational standards in the Indian Systems of Medicines and

Homoeopathy colleges in the country, strengthen existing research institutions and

ensure a time-bound research programme on identified diseases for which these

systems have an effective treatment, draw up schemes for promotion, cultivation and

regeneration of medicinal plants used in these systems and engage in standards

development for Indian Systems of Medicine and Homoeopathy drugs.

Critical Support Staff: Nurses and Para-medical Personnel

Since independence, a large number of training institutions for the development of

different categories of paramedical workers and auxiliaries were set up. These

included general nursing, ANM, midwifery, health inspection/sanitary inspection,

laboratory training, medical microbiology, medical entomology, audiometry,

radiology, and electronic technique, health education, health statistics, dietetics,

medical record officers course and medical record technician course (FRCH, 1987).

The Central Family Planning Training Institutes trained district level medical officers

while Regional Health and Family Welfare Centers were responsible for training the

PHC staff. Training of ANMs and multipurpose workers is intended through an


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elaborate network of State Institutes of Health and Family Welfare (SIHFW), Health

and Family Welfare Training Centers (HFWTC), District Training Centers (DTCs)

and ANM Training Centres (ANMTCs). Many of these too suffer from shortages of

good faculty and adequate budgets. Similar is the situation with the 47 HFWTCs in the

country for which the country releases over Rs.16 crores every year (GOI, 2005)

Nurses and midwives play a critical role in health promotion, prevention, therapeutics

and rehabilitation. There are 0.8 million general nursing midwives, 0.5 million

auxiliary nursing midwives in the different states (see Tables below). It is estimated

that only about 40% of the nearly 1.4 million registered nurses are currently active in

the country because of low recruitment, migration, attrition and drop-outs due to poor

working conditions (GOI, NCMH, 2005).

Number of Registered General Nursing Midwifery, Auxiliary Nurse-Midwives and

Table: 5.7 Details of Health Visitors in State Nursing Council and Board of

Examination in India

General Nursing

Midwives

Auxiliary Nursing

Midwives

Health Visitor &

Health Supervisor

Andhra Pradesh 84306 94395 2480

Assam 9659 12187 0

Bihar &

Jharkhand

8883 7501 511

Gujarat* 85406 35780 1352

Haryana 15821 13112 694

Himachal Pradesh 7888 9024 411

Karnataka 48458 46817 6836

Kerala 71589 27612 748

Mahakoshal &

Chandigarh

92158 25344 998

Maharashtra 79004 24910 556

Mizoram 1555 1410 0

Orissa 45830 30077 110

Punjab & Delhi 40568 16281 2584

Rajasthan 31063 21932 850

Tamil Nadu 155647 52341 11053

Tripura 639 969 79

Uttar Pradesh +

Uttaranchal

17353 26956 0

West Bengal* 44035 55855 11274

Total 839862 502503 40536

*Nurses Registered up to Dec. 2005.


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Bihar = 2002, Orissa = 2001, Mizoram = 2001 & Haryana = 2001.

Assam = Assam+ Arunachal Pradesh+ Manipur+ Meghalaya+ Nagaland.

Bihar = Bihar+ Jharkhand. Mahakaushal = Madhya Pradesh+

Chhatisgarh.

Maharashtra = Maharashtra+ Goa. Punjab = Punjab+ Delhi+ J&K.

Tamil Nadu = Tamil Nadu+ Andaman & Nicobar Islands+ Pondicherry.

West Bengal = West Bengal+ Sikkim.

Source: Ministry of Health & Family Welfare, Govt. of India accessed from

indiastat.com

Some of the key concerns and challenges pertaining to human resources in India

are : Information on human resources

The database maintained by the Medical Council of India (MCI) is the only

comprehensive information on the total numbers of doctors in the country, both

statewise and yearwise. However two significant lacunae need to be kept in mind.

First, as the various state councils (except for Delhi), have not been able to establish a

periodic renewal of registration, the MCI data is cumulative and does not reflect

attrition (due to death, retirement etc), being out of practice or migration of doctors

(within the country or overseas). Further, a doctor may be registered with more than

one State council in cases where one is practicing in a State other than the one where

s/he is first registered. This may lead to duplication of registration of doctors. Under

these circumstances the actual numbers of practicing doctors in the country should be

assumed to be less than the given figures. Secondly, except for the State of Assam and

Sikkim, none of the northeastern states have State Councils. Hence, doctors in these

states are likely to be registered with other state Councils. Therefore, statewise

distribution of doctors in these states is not currently available in the public domain.

Furthermore, the MCI register does not provide specific information on the numbers

and distribution of different types of specialists in the country.

The problem is that the Councils, particularly at the state level are not able to enforce

periodic renewal of registration. Therefore, there is no mechanism for incorporating

attrition, migration or dropouts of workers once they are in the register. The total

available figures may represent an inflated version of the numbers of workers that are

currently available for the health system. As in case with allopathic doctors, the

registers of State Dental Council are not updated to account for attrition, migration etc


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and information on distribution of dentists is not contained in these registers.

Information on dental mechanists and dental hygienists is not readily available.

However, currently attempts are underway at developing an information base for

health workers through the Indian Dental Association and nursing fraternity.

Data on workforce in private sector is hard to come by. In fact, there is very little

reliable data even on the total strength of active medical and other health care

professionals in any state. A study in Tamil Nadu estimates that as of December 1997,

there were a total of 37,733 allopathic physicians in the state of which about 10,000

physicians were employed in government services (Muraleedharan, 1999b). This

means there are about 70% of physicians were in private sector in these states. We

have no estimate of how they are distributed across rural and urban areas. However it

is not difficult to imagine. In and around Chennai city alone, about 10,000 doctors

(including those in private and public sectors) are located. Likewise, about 35%, of an

estimated 2035 dentists in Tamil Nadu, was located in and around Chennai city.

Education, training and professional development

Over the years since the time of independence an intense introspection has

raged about the relevance of medical education to the health needs of the country.At

present there is an acute shortage of good teaching faculty in medical colleges,

particularly in pre and para clinical subjects like anatomy, physiology, biochemistry,

pathology microbiology, pharmacology, forensic medicine and community medicine

(GOI, NCMH, 2005). These subjects have received less attention and importance and

are less developed, thereby not being considered as most attractive options for

postgraduate students. This is coupled with the bureaucratic environment in

government medical colleges leading to drawing away of senior teaching faculty from

public to private colleges with better salaries and more flexible work environments. A

major constraint to the present and future development of medical personnel is lack of

adequate and good quality faculty. This must be factored into any future projections

for production of medical workers and before a rapid expansion of educational

institutions Instances of a few alternative models do exist, but no radical changes in

the design of medical education have taken place since the time the William Bentinck


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Committee outlined its six key principles of medical education: in strict accordance

with the mode in Europe; instruction in English; course for 4-6 years; instructions in

anatomy, surgery, medicine and pharmacy; witness the practice in various hospitals

and dispensaries; public services be supplied with doctors from these institutions

(Crawford, 1914).

Another issue is around the quality of medical education. On the one hand,

serious concerns have been expressed about the dilution of technical standards in

medical and paramedical education due to lack of effective regulation and adequately

skilled faculty. On the other hand it is also clear that existing standards and curricula

need a stronger community and rural orientation to make them more appropriate to

meet the goals of public health. Equally, innovations in medical education and training

are urgently needed to recruit and create a cadre of basic health providers who are

willing to live and work in rural areas of the country. The focus of medical education

needs to move away from maintaining an over- dependence on doctors and specialists.

Education and training in nursing and paramedical professions

The nursing education has also witnessed shortfalls in the quality of education due to

inadequate infrastructure, insufficient budgets, non-adherence to student-teacher

norms, lack of commitment and accountability in educators for clinical supervision

and guidance and insufficient hands-on training for students. In 2004, 61.2% of the

635 nursing schools and 165 nursing colleges were found unsuitable for teaching. De-

recognition by the Indian Nursing Council has no impact as they continue to function

with the permission of the State Nursing Councils (GOI, NCMH, 2005). There are

also no specialized nursing disciplines in India like nurse anesthetists or nurse

practitioners and no formal system exists for the training of nurses and midwives to

keep them abreast with the latest developments in the field.

As an important step towards promoting quality nursing education and practice in

India, a National Consortium for Ph D in Nursing was established under the active

leadership of the Indian Nursing Council, seven leading nursing institutions of India,


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WHO-India, and the Rajiv Gandhi University of Health Sciences (RUGHS),

Bangalore. The establishment of a National Consortium is a unique and innovative

approach to strengthen the nursing education, where nursing institutions of India have

come together along with RGUHS, INC and WHO-India.

The NIMHANS, Bangalore, has been selected as the nodal center for the Ph D

course. In the case of paramedical professions too, like pharmacy and laboratory

technology, there is considerable diversity and dilution of standards of education.

Pharmacy education is guided by a Pharmacy Council but in the absence of

enforcement of regulations, many unlicensed institutions provide diploma courses in

pharmacy. There is no separate council to guide the training of laboratory technicians.

Regulation need to be liberalised:

In India, there exists legislation with respect to licensing of medical professionals such

as doctors, nurses, dentists and pharmacists with a view to control their entry into the

market. Statutory regulatory councils have been established to monitor the standards

of medical education, promote medical training and research activities, and oversee

the qualifications, registration, and professional conduct of doctors, dentists, nurses,

pharmacists, and practitioners of other systems of Medicine such as Ayurveda, Yoga,

Unani, Siddha and Homeopathy. Important of these laws are: the Indian Medical

Council Act, 1956, the Indian Nursing Council Act, 1947; the Indian Medicine Central

Council Act, 1970; the Homeopathy Central Council Act, 1973; the Dentists Act 1948

and the Pharmacy Act, 1948. Almost all of these laws establish councils that set forth

uniform educational and qualification standards and establish a central registry for

certified individuals. Finally, councils often prescribe standards of professional

conduct and determine which actions amount to professional misconduct.

The various Medical Councils serve mainly to protect the interests of an exclusive

medical membership and do not adequately prescribe or promote quality issues that

are relevant in current times. They have also not been able to enforce renewal of

registration or take action against erring members. Furthermore, there exists on

legislative framework for regulating the functioning of the paramedical personnel.

There is also no enabling legislation for the non-formal sector in support of their

health functions.


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The private health sector in India has grown without any regulatory frameworks and

this has contributed in many ways to non-uniform quality of care, arbitrary pricing and

the absence of either a minimum set of norms for setting up a clinic or nursing home,

or systems for continuous quality improvement and assurance. There is a strong

argument for a minimum set of basic regulations covering the licensing of

practitioners and institutions, measures to ensure minimum standards of quality,

guidelines regarding pricing, and actions to prevent the oversupply of services

including technology in the private sector. This also means examining existing laws

that are outdated and making appropriate changes or devising new comprehensive

legislation.

Planning and Strengthening of Human Resources: Workforce Planning

Currently there is no clear system of projecting the future supply of human resources

vis-à-vis the population’s need and demand even with reference to International

Healthcare needs. Prior to planning for human resources, a systematic appraisal of

human resources needs to be undertaken. Such an appraisal of human resources should

include an assessment of the current workforce and future requirements with respect to

the needs and demands of the population and the health system. A variety of

diagnostic and planning tools such as simulation models and scenario planning for

forecasting, projecting and planning human resources are available and have been

used in developing countries (Starkiene, et al., 2005). The WPRO/RTC health

workforce planning workbook is one such tool that provides steps for developing an

HR plan and includes a simple computer based planning model (Dewdney, 2001) Lack

of policies for human resource development in the public health system Human

resource policies cover all those factors that influence the performance and

commitment of workers in any work situation. These include appropriate incentives

for performance (financial and others), autonomy in decision-making, career

development opportunities, transparent policies for transfers and promotions, in-

service training opportunities, regular performance appraisals and monitoring and

supportive supervision.

Partnerships with the private for-profit and not-for-profit sector: Partnerships

between the public sector and the private sector are one way of reducing gaps in the


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supply, needs and demands for human resources, in improving the organizational

efficiency of public sector facilities and of better leveraging available human

resources. These partnerships can take the form of clear contractual arrangements or

simply be collaborative endeavors between two or more partners. Additional options

for partnerships include contracting private doctors to fill up public sector vacancies

and financing emergency maternity services for the poor through the private sector

(Muraleedharan and Nandraj, 2003). In the state of Uttaranchal, for example, the

Health Department has appointed 187 Medical Officers, 44 Lady Medical Officers and

258 ANMs on a contractual basis (GOI, 2004).

Permitting Brain drain in Healthcare Sector that will make India to explore the

Medical opportunities in the years to come:

The rise in migration of health personnel for work abroad has gained attention

in recent years in the context of the WTO agreement under GATS – Mode 4 as it has

important ramifications for both countries of origin and countries of destination. There

is already substantial movement of medical personnel from South to North and

between countries of the developing world. The potential for exchange of medical

personnel between countries is attested by experience from across the world.

Developing countries – particularly from Asia – supply over half of all migrating

physicians, with around 100,000 doctors of Indian origin settled in the USA and UK

alone. Indian doctors, nurses, technicians amongst others deliver services in the

Middle East on short-term bilateral contracts. Most of migration in health care sector

is permanent. The main advantage is due to availability of low cost, well trained, high

quality health care providers from India. Active international recruitment by national

health systems has generated a particularly high level of cross-border mobility among

nurses.

For the available data for the year 2002 India was the most important source

country for registered nurses under H1A category to the US around 81,091 nurses

compared to 15,838 for China, 5,509 for Philippines. This phenomenon migration of

health service providers under Mode IV of GATS, is viewed as a source of skills

acquisition, investment and foreign exchange earning (through remittances). The

demand for movement is factored by the desire of individuals to seek higher wages;


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better working conditions and other benefits of employment opportunities abroad. A

large number of those countries which export doctors and nurses experience severe

shortages themselves. Increased trade in health services risks exacerbating this transfer

of medical personnel from developing countries to the developed countries thereby

placing an even greater strain on health systems in the latter. Weighed against these

losses, the remittances, which medical personnel send home, and the enhanced skills

they bring with them if and when they return, need to be examined. Further there is a

need to study issues related to migration of health personnel.

One of the most pressing considerations associated with health services trade is

brain drain, both internal, that is, within developing countries from the public to the

private sector and external, that is, between countries, typically from developing to

developed countries. The cases of India, South Africa, and various other developing

countries discussed earlier, clearly highlight the problem of external and internal brain

drain. The common underlying factors contributing to this brain drain are, as

mentioned earlier, low wages, poor working conditions, poor infrastructure and

facilities, inadequate investment in health care, lack of opportunities for upgrading of

skills and knowledge, and also political and social conditions. This implies that if

brain drain is to be tackled, either by retaining health professionals or by attracting

back those who have left the country, then these root causes have to be addressed. The

various country cases discussed above indicate that most countries have done little to

address these underlying conditions. A few countries such as India and South Africa

have introduced policies to delay emigration such as by insisting on a period of public

service following graduation or by delaying certification till after public service has

been rendered. The cases of Cuba and China are, however, useful for highlighting the

possibilities for exporting health service providers on short-term contracts whereby the

benefits of such outflows in terms of foreign exchange earnings, exposure, and

bilateral assistance are reaped without the attendant problem of brain drain. Policies

need to be introduced, unilaterally and in cooperation with key host countries, to

address brain drain. Some concrete measures are outlined below.


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Movement of persons can be permitted on short-term bilaterally negotiated

assignments between developing and developed countries for fixed periods or on

short-term exchange programmes. This would yield benefits associated with increased

exposure and upgrading of skills for health professionals and foreign exchange

earnings while overcoming the problem of permanent outflows. The preceding

discussion has highlighted the case of countries such as Cuba that have adopted this

strategy. There is need for bilateral cooperation between receiving and sending

countries to manage cross-border flows of health service providers in line with

host and home country supply and demand conditions. Bilateral cooperation could be

in the form of host countries compensating the sending countries through assistance

agreements or ensuring that the latter’s health professionals return after serving a fixed

period. This is also possible through cooperation on immigration and labour market

policies, such as under special visa schemes and recruitment programmes for overseas

health professionals, so as to regulate the movement of health professionals in

accordance with the needs and interests of both receiving and sending countries.

Bilateral cooperation is also required to promote links between emigrating

professionals and skilled nationals to reduce the negative effects of brain drain in the

sending countries. · Unilaterally, source countries can adopt several policy measures

to stem brain drain. In cases where sending countries have a major shortages of health

service providers and where outflows could seriously hurt availability and quality of

services in the public health system, negative incentives could be introduced to reduce

emigration, such as through a migration tax or by requiring emigrating professionals to

refund the training costs incurred by the government.

Positive incentives in the form of deductions and tax exemptions and measures to

improve working conditions and facilities and to increase opportunities for

professional development, need to be considered.

If Required GOI can delay migration of Healthcare Professional in the interest of

Nation:

Emigration can also be delayed by asking health professionals to serve a mandatory

period within the home country following their training so as to pay back society.


213

Where public services are involved, countries could delay the training period to ensure

that certification follows a period of public service rendered to the home country.

Efforts can also be made to induce expatriate health professionals practicing abroad to

contribute to their home country’s health sector. This can take the form of official

programmes to attract health care professionals to return to their home countries under

return of talent programmes (as some countries have done), by establishing

arrangements whereby expatriate health professionals can provide services to the

home country through visiting and contractual appointments and through collaborative

research and teaching arrangements, by setting up “brain gain” networks of expatriate

health care providers, by establishing on-line communication with doctors and medical

professionals, and by encouraging foreign investment by the expatriate community.

Marketing Globally:

The world is getting ‘flatter’; people, information, technology, and ideas are

increasingly crossing national borders. Healthcare is not immune from the forces of

globalization. Competition from medical tourism and the rapid growth in the number

of undocumented aliens requiring care represent just two challenges healthcare

organizations face. An international workforce requires leaders to confront the legal,

financial, and ethical implications of using foreign-trained personnel. Cross-border

institutional arrangements are emerging, drawing players motivated by social

responsibility, globalization of competitors, growth opportunities, or an awareness of

vulnerability to the forces of globalization148

.

What factors have been important in the success of those organizations that have made

inroads in the international market? First of all, having an international brand

reputation can give global marketing efforts a boost. The Mayo Clinic, which boasts

10,000 patients annually from 120 countries, and Johns Hopkins, which boasts 7,000

patients annually from 90 countries, are two examples of internationally recognized

148

Fried BJ, Harris DM, “Managing healthcare services in the global marketplace”, Source Department

of Health Policy and Administration, School of Public Health at the University of North Carolina

(UNC) at Chapel Hill, USA.


214

brand names. These organizations work hard to build and maintain their brands

internationally while they market to international patients.

Having internationally known physicians on staff also can help a health services

organization break through to the international market. Many organizations attract

foreign business through the work of key physicians and surgeons. These

practitioners--who may come out of research, clinical care, or even teaching settings--

typically bring public awareness and referrals to key service lines.

While having an internationally recognized brand is a distinct advantage, hundreds of

lesser-known healthcare organizations are attracting foreign patients to their facilities

as well. So whether your organization already enjoys a large base of international

business or is currently building an international program, having a detailed business

strategy and a solid marketing plan are critical. In fact, unless you happen to be one of

the top-tier medical centers with a highly recognized brand name that will

automatically attract international interest, marketing is crucial. Those institutions can

afford to spend less money on aggressive marketing because they can fall back on

their well-known names to attract referrals and patients. Smaller, less well-known

medical centers, which comprise the bulk of institutions, must invest more to generate

awareness and referrals to their programs.

Standing out in a Crowd

Marketing to international patients means more than just offering a little information

in Spanish on your Web site. It requires a dedicated business effort with operational

and clinical support throughout the organization. Assuming you can build a team that

will focus on the special needs of these patients, a number of general marketing and

communications strategies may help build your reputation, draw attention to your

services, and attract new patients.

First of all, it's important to create a Web site that addresses international patients.

While the Web isn't the answer to international marketing, it is a critical component of

a good marketing program for obvious reasons. Organizations that have built

http://web.ebscohost.com/ehost/detail?sid=897fb74c-b36f-4697-b46f-e21704a6e040%40sessionmgr10&vid=13&hid=24&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#toc


215

successful international patient programs steer patients to dedicated Web sites, offer

multiple languages, and provide support services and dedicated staff to assist

prospective patients. Mayo offers customized forms (e.g., need a Turkish International

Appointment Request Form?) on its Web site, which also link back to information

about the offices of their overseas representatives. That level of detail and

customization ultimately sets Mayo apart from the hundreds of other medical centers

that simply send a much broader and less targeted message abroad.

Having a well-trained call center and support staff also helps marketing efforts. Johns

Hopkins maintains an International Patient Services group through its Johns Hopkins

International (www.hopkinsmedicine.org/international) division, with staff that can

coordinate all aspects of a patient's care, including travel, cultural, and personal needs.

The Cleveland Clinic International Center (www.clevelandclinic.org/ic) coordinates

much of The Cleveland Clinic's foreign business and patient contacts. Other providers

offer personal interpreters, travel and scheduling services, and call center operators to

answer toll-free numbers.

Another strategy is to have internationally based sales representatives and field

offices. Some organizations, such as The Cleveland Clinic, maintain overseas offices

as a way to deliver quick, customized information and services to specific markets.

Mayo maintains international representative offices in Turkey, Mexico City, and the

Middle East. While maintaining representatives abroad may seem like a significant

expense, the continuity of marketing contacts and referral channel management may

be well worth the investment.

Hosting tours for international business, consumer and civic groups is another way to

showcase your facilities and services to potential healthcare audiences. Often these

tours can be arranged through your local chamber of commerce or other business and

higher education groups and university contacts. Physicians and other healthcare

providers who travel abroad often help establish local contacts, referral sources, and

future business for their organizations. These efforts can be built around exchange

programs, mission trips, or educational conferences. In addition, medical schools and

http://www.hopkinsmedicine.org/international

http://www.clevelandclinic.org/ic


216

residency programs that train foreign physicians can serve as important links to

international referrals. Maintaining active alumni and graduate programs is an

important strategy for opening the door to foreign patients.

Likewise, many foreign physicians come to the United States on short trips for the

purpose of continuing medical education programs. These doctors represent possible

referral sources for new patients and complex cases as well. Referral development

should be a key strategy for any provider looking to attract international business.

Companies with international operations and foreign companies with operations may

also be sources for marketing to international patients. Many healthcare providers

have relationships with companies in their local markets but never explore the

prospect of leveraging those relationships to reach foreign patients.

It's also a good idea to coordinate with foreign government offices. The Embassy in

Madrid (www.embusa.es/medical/indexen.html) features a link on its homepage to

medicine. The site lists several hospitals from News & World Report's America's Best

Hospitals rankings as well as advice on how to contact healthcare providers.

(According to the site, cancer and ophthalmology are the two most requested service

lines.) providers might work with foreign offices to place their names on referral lists

as well as meet important diplomats and other government and social contacts.

Another strategy is to establish partnerships with chambers of commerce, economic

development groups, and other healthcare providers. A growing number of

communities are building sister-city programs, marketing overseas, and targeting

foreign investors. Healthcare providers should look for ways to partner with these

organizations to expand their reach and exposure. One innovative approach, called

Philadelphia International Medicine (PIM) (www.philadelphiamedicine.com), began

in 1998 when 10 healthcare organizations in the greater Philadelphia area formed an

initiative to focus on attracting and serving international patients. PIM, which serves

as a central point of access for international physicians and patients seeking care in

the United States, combines the marketing resources of a number of providers in a

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way no single facility could do as effectively. According to Leonard Karp, executive

vice president and COO for the organization, its success stems from several factors,

including senior management buy-in and support, one-on-one relationship building,

and excellent customer service, which results in strong word-of-mouth referrals from

previous patients.

In some cases, running ads in foreign publications and media outlets may make sense

and help generate inquiries and leads to international patient programs. While

healthcare providers don't need to throw money at just any international publication,

paid advertising and direct marketing as part of a coordinated marketing and

communications effort may be a good investment.

Highlighting recent successes, medical breakthroughs, new technology, and

exceptional physicians through coordinated public relations and media relations can

also help draw international attention to your organization. But this should be more

than the occasional press release. It requires a dedicated public relations program that

will work with foreign and domestic journalists to develop and place story ideas,

conduct media tours, and position the institution and its caregivers as key information

sources.

Another advantage of the Internet is the number of international medical directories

that have sprung up to help funnel referrals to healthcare organizations that pay to be

listed on these services. Medical Resources USA (www.medicalresourcesusa.com) is

one example. But marketers should be careful to research the sites, ask for details on

how they promote themselves and check with current advertisers to see how

worthwhile their listings have been.

THEME-BASED FINDINGS OF THE INTERVIEWS OF DOCTORS &

SENIOR HEALTHCARE MANAGERS OF THE MULTI-SPECIALTY/

CORPORATE HOSPITALS IN INDIA HAVE BEEN PROVIDED IN

THE TABLE BELOW.

Total Sample: 90 Respondents

No of Doctors: 56

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218

Senior Managers: 34

Table 5.8 Distribution of Sample Gender wise: Total

Sample: 90

SAMPLE

CATEGORY MALE FEMALE TOTAL

3. Doctors 42 14 56

4. Senior managers 29 05 34

Total 71 19 90

Table 5.9

Advantage of Skilled Work Force In International Markets

S.No

Opportunities

Yes No Yes No

No of

Doctors % No of

Doctors % No of

Managers % No of

Managers %

1. JCI and NABH

accreditation will

lead to better

quality

32 58 24 42 14 41 20 59

2. Greater Mobility of

Human Resources 48 86 8 14 34 100 0 0

3. Specialised

procedures, low

cost, skilled staff

and superior

Technology will

foster betterment

54 97 2 3 33 97 1 3

SAMPLE DISTRIBUTION

Doctors

Senior Managers


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4. Political and

economic stability

of India

10 18 46 82 8 23 26 77

5. Less effect during

Recession 49 88 7 12 29 85 5 15

6. Obama Healthcare

Reform, boon for

India

48 86 8 14 29 85 5 15

7. Leads to Tourism

development 51 92 5 8 31 91 4 9

8. Will leads to

development of

Insurance sector

47 84 9 16 30 88 4 12

Average 43 77 13 23 26 76 8 24

Ref: (S. No 1) From the above analysis it is clear that 58 percent of Doctors are under

impression that JCI and NABH accreditation will lead to better quality of healthcare

delivery and same has been said by 41 percent Senior managers of various corporate

hospitals. But 42 percent of doctors & 59 percent of senior managers hold a different

opinion. It is interesting to note that both doctors & Senior managers are favoring

accreditation from JCI & NABH.

Ref: (S. No 2) From the above analysis one can understand that 86 percent of Doctors

opined that Internationalisation of Indian healthcare will activate movement of

Healthcare personnel from home country to abroad vis-à-vis and same has been said

by all the Senior managers of various corporate hospitals. But 14 percent of doctors

hold a different opinion.

Ref: (S. No 3) From the above analysis it can be concluded that 97 percent of Doctors

are under impression that Globalisation of Indian Healthcare services will grow

because of Specialised procedures, low cost, skilled staff and superior Technology will

foster betterment same has been said by 97 percent Senior managers of various

corporate hospitals. But 3 percent of both doctors & senior managers hold a different

opinion.

Ref: (S. No 4) From the above analysis it is clear that 18 percent of Doctors said there

will not be any affect on Indian Political & Economic environment and same has been


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said by 33 percent Senior managers of various corporate hospitals. But 82 of doctors

& 77 percent of senior managers hold a different opinion. It appears to the researcher

that the doctors & senior managers have concern about the Indian Political &

Economic environment

Ref: (S. No 5) From the above analysis it is very interesting to note that 88 percent of

Doctors said the recession that was hit the world in the recent past did not affect

Indian Healthcare much and same has been said by 85 percent Senior managers of

various corporate hospitals. But 12 percent of doctors said there has been affect and 15

percent of senior managers hold same opinion.

Ref: (S. No 6) From the above analysis it can be concluded that 86 percent of Doctors

said recent reforms initiated by Mr. Barak Obama President of US will help Indian

Healthcare sector and same has been said by 85 percent of respondents among the

sample of Senior managers of various corporate hospitals. But 14 percent of doctors &

15 percent of senior managers hold a different opinion.

Ref: (S. No 7) From the above analysis it can be stated that 92 percent of Doctors said

healthcare internationalisation will pave way for simultaneous growth of India

Tourism and same has been said by 91 percent of Senior managers of various

corporate hospitals. Now a days patients are planning to explore both pleasure &

Healthcare. But 8 percent of doctors & 9 percent of senior managers hold a different

opinion.

Ref: (S. No 8) From the above analysis it can be stated that 84 percent of Doctors said

healthcare internationalisation will pave way for simultaneous growth of India Health

Insurance as well and same has been said by 88 percent of Senior managers of various

corporate hospitals. Most of patients would like to get the advantage of Health

Insurance coverage. Now Indian counter parts also would like to join the hands with

International Insurance Providers. It’s a great sign that more MNCs will start their off

shore operations in India.


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Conclusion:

Given the growth of the global healthcare opportunities and the reputation for Indian

healthcare excellence, it's only natural that more healthcare businesses will explore

ways by supplying skilled manpower in to global healthcare there by catering

international patients. While the United States' Canadian and Mexican neighbors

already provide a steady flow of experts to healthcare facilities, many providers are

finding a rich source of patients in Europe, Asia, the Middle East, and other parts of

the world as well.

And other healthcare organizations--not just hospitals and physicians--are discovering

investment opportunities abroad but also health insurers, home health companies,

medical manufacturers, and healthcare technology companies all are experimenting

with exporting their expertise and products while importing new sources of revenue

and growth. Competition from medical tourism and the rapid growth in the number of

undocumented aliens requiring care represent just two challenges healthcare

organizations face. An international workforce requires leaders to confront the legal,

financial, and ethical implications of using foreign-trained personnel. Cross-border

institutional arrangements are emerging, drawing players motivated by social

responsibility, globalization of competitors, growth opportunities, or an awareness of

vulnerability to the forces of globalization.

With globalization and spread of Internet the world is becoming a big mart

with consumers shopping for best value of money across political boundaries. This is

opening a global customer base for the product and service providers. Developing

countries too are using this opportunity to create their own competitive advantages.

Information Technology sector is already witnessing the power of competitive and

differential advantage of developing nations and healthcare is emerging as another

potential area. The health services at reasonable prices - at least in comparison to the

developed countries, are attracting large number of people from across the globe to a

few select destinations. Globally this market is estimated to be to the tune of US$ 40

billion growing at the rate of 15 per cent per annum. India is the new entrant in the

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field that has seen an upward trend in attracting the foreign tourists for medical

purposes in the recent years and is counted among potential frontrunners. While on the

one hand its medical tourism is lauded for its revenue generation and service

excellence capabilities, on the other hand doubts are also being raised about a number

of related issues pertaining to real advantages to patients as well as service providers.

It can be stated that assessment of the existing trends, infrastructure required for

exploring medical tourism and encash the advantages that India possesses besides

taking stock of the trends in medical tourism at the global level.

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