Country experience: India Health Services Survey
As an initiative to collect and compile dis-aggregate level services trade statistics, the first ever pan-India survey on export of health services was conducted by the Indian Directorate General of Commercial Intelligence and Statistics (DGCI&S). The survey was conducted between June 2016 and March 2017.
Globally, trade in health services is growing. This is being facilitated by several factors such as advances in information and communication technology (ICT), liberalisation of foreign investment and easier visas for mobility of patients. Today, developing countries such as India are able to offer state-of-the-art healthcare facilities at affordable prices due to the availability of qualified manpower and internationally accredited hospitals. These countries have emerged as affordable health and medical tourism destinations. Along with modern treatment, countries such as India and Thailand also offer a wide range of traditional healthcare treatments such as ayurvedic treatment and Thai massages. Such treatments are becoming extremely popular across the globe. On the supply side, lack of domestic healthcare facilities, long waiting time for treatment, high costs and lack of personalised care are some of the reasons for which patients travel to countries such as Malaysia, India, Singapore and Thailand for treatment. These patients are from a wide range of countries including developed countries such as the United States (US) and the European Union (EU), African countries, the Middle East and Commonwealth of Independent States (CIS) and even neighbouring countries such as Bangladesh, Pakistan, and Afghanistan. According to industry estimates, around seven million patients are said to be travelling around the world each year to receive medical care.
Given India’s strengths in terms of the availability of highly skilled manpower, low cost, state-of-the-art hospitals and capabilities in areas such as telemedicine and clinical trials, the country has become a hub for providing healthcare services. The Government of India (GoI) has taken several measures to support the development of India as a healthcare hub and the country’s export in this sector is growing. Nevertheless, there was no official data to estimate the export of health services. To overcome this gap, the Department of Commerce in consultation with the Directorate General of Commercial Intelligence and Statistics (DGCI&S) has identified health services as a key sector for a primary survey of enterprises in healthcare services to capture the export data. This report is based on the primary survey conducted by the DGCI&S on International Trade in Health Services for the reference period 2015-16.
This survey was conducted under the Collection of Statistics Act, 2008. In total DGCI&S had a sampling frame of 1,346 enterprises, of which a sample of 435 enterprises was covered in the survey conducted between June 2016 and March 2017.
The key findings of the survey are as follows:
• During the financial year 2015-16, medical or health tourism has been the largest contributor (70%) to India’s total health services exports of USD 890 million; followed by contract research (27%).
• In terms of region-wise export earnings, Asia accounts for more than 60 per cent of the foreign exchange earnings followed by 14 per cent from the US and 11 per cent from Europe.
• In terms of the number of patients, close to 70 per cent of the foreign patients are from Asian countries followed by 9.3 per cent from the US and 8.9 per cent from Africa. Less than 2 per cent of the patients came from Europe and the CIS countries.
• In 2015-16, Bangladesh accounted for more than 35 per cent of the foreign patients and more than 50 per cent of the total revenue from medical tourism, making it the largest contributor to medical and
health tourism. Other countries reporting a significant number of patients travelling to India for medical services are Iraq, Maldives, Afghanistan and Nepal.
• By discipline, orthopaedics accounted for the highest export earnings of around USD 82.3 million while ophthalmology attracted the maximum number of foreign patients— close to 38,500—during the survey period 2015-16.
• In terms of export earnings, orthopaedics, cardiology, neurology, ayurveda and oncology were among the top five contributors to export earnings.
• Per patient realisation was the highest for haematology (USD 10,315) followed by cardiology (USD 4,159), paediatric surgery (USD 4,040), plastic and reconstructive surgery (USD 3,292) and dentistry (USD 3,097). The amount is directly related to the cost of treatment.
• The average earning per patient was found to be USD 1,350 with the highest contribution per patient coming from Pakistani nationals (USD 2,906), followed by Bangladesh (USD 2,084), other CIS countries (USD 1,950), Russia (USD 1,618) and Iraq (USD 1,530) As in the case of any primary survey, DGCI&S faced several issues in conducting this survey. One of the major challenges faced was the absence of a business directory for service providers in the health sector. Since comprehensive data for health service providers is not available, DGCI&S had to create a business directory to conduct the survey. It was a cumbersome and time-consuming process. Moreover, the information provided by enterprises surveyed was not complete. In some cases, hospitals were not able to provide country-wise and discipline-wise data for patients.
Based on the experience gained from conducting the survey and the responses received, the following recommendations have been made:
• There is need to create a business directory with complete contact details and addresses. The business directory should be updated regularly, preferably once a year.
• It should be made mandatory for government hospitals to report details of foreign patients and foreign collaborations to the Ministry of Health and Family Welfare (MoH&FW), which can share the information with the Department of Commerce and the DGCI&S. Similarly, the Ministry of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) should also update the database of wellness and alternative medical treatment centres. It is important to have a database of dental and cosmetic surgery centres/clinics in each state. Enterprises in clinical trials are registered with the MoH&FW. This database has to be updated regularly and shared with the DGCI&S through the Department of Commerce.
• Enterprises should be encouraged to participate in the survey and submit the data in the prescribed format. Suitable awareness building initiatives have to be undertaken before the launch of a survey in order to sensitise service providers to the benefits of such surveys. Assurance has to be given to service providers that no confidential information will be put in the public domain. Respondents should also be made aware of their responsibilities under the Collection of Statistics Act, 2008.
• The key findings of the survey may be presented in different cities for awareness building.
• The field survey will require adequate budget allocation and capacity building. Appropriate funds may also be allocated to the DGCI&S to promote and to advertise such survey.
• The coverage of the survey should be widened to ensure the collection of complete information on international trade trends from the health sector. There is need to collect data on the import of health
services. Units exclusively offering other health services including contract research, telemedicine and clinical trials should also be covered during the survey.
• A number of doctors, nurses and other healthcare service providers registered in India work abroad in different countries. Periodic compilation of this information will be useful in capturing the contribution of medical professionals to the exports of health services. This can be done through collaborative projects such as the European Commission (EC) funded India-EU Capacity-building Initiative for Trade and Development (CITD) project and other similar projects that provide a platform to build India’s capacity to have a better trade data collection mechanism. The Trade Policy Division of the Department of Commerce should be made a key beneficiary in such trade related capacity building inter-government projects/ initiatives.
• To get a time series data, DGCI&S should take up this survey on an annual basis.
More information on this survey can be found in the official report of the survey, Export of Health Services A Primary Survey in India, available here: http://dgciskol.nic.in/pdfs/Export_of_Health_Services_Final_Book_Report.pdf
1 DGCIS, Export of Health Services A Primary Survey in IndiaI, April 2017. http://dgciskol.nic.in/pdfs/Export_of_Health_Services_Final_Book_Report.pdf