UNIVERSITY OF PETROLEUM & ENERGY STUDIES

College of Management and Economics Studies, Dehradun

Project Report
On

Identifying & implementing marketing strategies for International Business, Patient Referrals
& Medical Tourism

(Summer Internship Program)

Bachelor of Business Administration
(with specialization in Foreign Trade)

2014-2017

Submitted to:

Mr. Rachit Srivastava

Marketing manager
Konsult App

Submitted by:
Dr. Rajeev Sharma Gayatri Tandon
Asst. Professor - SG 500035464
Program Head (BBA Foreign Trade) R122214012
UPES, Dehradun

Acknowledgement

The internship opportunity I had with Konsult was a great chance for learning and professional development.

Therefore, I consider myself as a very lucky individual as I was provided with an opportunity to be a part of it. I am
also grateful for having a chance to meet so many wonderful people and doctors who led me

though this internship period.

Bearing in mind previous I am using this opportunity to express my deepest gratitude and special

thanks to the MD of [Company name] who in spite of being extraordinarily busy with her/his

duties, took time out to hear, guide and keep me on the correct path and allowing me to carry out

my project at their esteemed organization and extending during the training.

I express my deepest thanks to Mr. Rachit Srivastava, Marketing manager, for taking part in

useful decision & giving necessary advices and guidance and arranged all facilities to make life

easier. I choose this moment to acknowledge his/her contribution gratefully.

It is my radiant sentiment to place on record my best regards, deepest sense of gratitude to Dr.

Puneet Agarwal, Mr. Anshul Mittal, Mr.Kailash Satyarthi and Mr. Tarun Kumar for their careful

and precious guidance which were extremely valuable for my study both theoretically and

practically.

I perceive as this opportunity as a big milestone in my career development. I will strive to use

gained skills and knowledge in the best possible way, and I will continue to work on their

improvement, in order to attain desired career objectives. Hope to continue cooperation with all

of you in the future.

Gayatri Tandon
BBA Foreign Trade

Table of Contents Page No.

1. Acknowledgement 2
2. Table of Contents 3
3. List of Figures & Tables 4
4. Executive Summary 5

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5. Overview of the organization 6
6. Research Objectives 7
7. Patient referrals & Marketing Strategies 8
8. Technology & Consultation 13
9. Benefits of Application 24
10. Medical Scenarios over the World 28
Kyrgyzstan 31
Kenya 37
Nigeria 47
Congo 52
11. India- a premiere health care destination 56
12. Healthcare & Medical International Trade Regulations 64
13. Investing in the healthcare sector 67
14. Conclusion 71
15. References 72

List of Figures & Tables

Page No.

1. Figure 1 International Market Entry Options 12

2. Figure 2 A rural clinic 22
3. Figure 3 Academic medicine flourishes in private sector 30
4. Figure 4 News Article 34
5. Figure 5 HIV/AIDS in Keya statistics 39
6. Figure 6 HIV/AIDS prevalence in Kenya 40
7. Figure 7 UNICEF help in Borno 51
8. Figure 8 Medical Tourism arrival in India 58
9. Figure 9 Therapy for growth 62
10. Figure 10 An imported scanner 70
11. Table 1 Selected Internet telehealth resources 20

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 12. Table 2 Examples of federal agencies' health information web sites 20
13. Table 3 Kyrgyzstan GDP estimates 2015 31
14. Table 4 Kenya population 37
15. Table 5 Kenya GDP 37
16. Table 6 List of medical tourism companies in Kenya 46
17. Table 7 Nigeria population 47
18. Table 8 Nigeria GDP 47
19. Table 9 DR Congo population 52
20. Table 10 DR Congo GDP 52
21. Table 11 Foreign patients travel to India 56
22. Table 12 Foreign tourist arrivals growth 58
23. Table 13 Foreign tourist arrivals to India in 2013 59

Executive Summary

This report comprises of a study of identification and implementation of marketing strategies for
International Business, Patient referrals and Medical Tourism. Konsult app is an application
which was basically the idea of Dr. Puneet Agrawal, Mr. Anshul Mittal and Mr. Kailash
Satyarthi. They came up with the idea to connect doctors and their patients through a mobile
application, along which doctors get their consultation fees on a per minute call basis and are
also able to meet new patients who need the medical support of such doctors. Patients may send
their doctors an image of their reports through a chat option available on the application, which
shall enable the doctor to advice medication.
In a time of increasing demands on physician productivity, computer and communication
technologies allow health professionals to experiment with many applications that may provide
opportunities to meet clinical demands while still participating in educational and research
activities.
Educational opportunities are growing exponentially for those who cannot attend traditional
courses because of limited time or geographic considerations. Research and medical information
and medical consultations are being delivered instantly across wide geographic areas. Nearly

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every federal agency has a web site providing health information. Integrated clinical
management systems can facilitate the management of patients with chronic diseases and provide
an efficient way to integrate consultations and patient education, monitoring, follow-up, and
support.

Overview of the Organization

Konsult application started in July 2015 was the icdea of Dr. Puneet Agrawal, Mr. Anshul Mittal
and Mr. Kailash Satyarthi. Dr. Agrawal works as a neurologist with Max super specialty hospital
in Saket, New Delhi and Mr. Mittal is a lawyer by profession.
Konsult came into being with the thought of collaborating technology and consultation with an
end result of online consultation i.e. through a mobile phone application.
With the rise of medical tourism sector in India there is a huge amount of follow ups that take
place. It is not economical for foreign patients to travel for hours into another country every
month for a checkup.
Hence, to avoid such hectic situations, Konsult app makes it easier by providing specialist Indian
doctors on their panel who easy accessible to their patients through a phone call.
Doctors on the panel set the consultation fees on a per minute call basis, which is shared between
the doctor (70%) and Konsult (30%).
Main office:
136/2, Begumpur,
Shivalik Link Road,

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Malviya Nagar, New Delhi,
Delhi 110017
Total staff strength - 25

Research Objectives

1. To assess how global marketing strategies have an impact on international marketing.

2. To evaluate how technology & consultation can go hand in hand.
3. To evaluate the rise of Medical Tourism in India from countries like Kyrgyzstan, Kenya,
Nigeria & Congo.
4. To see how the international trade regulations have an impact on this sector.

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Patient Referrals
In medicine, referral is the transfer of care for a patient from one clinician to another.
Tertiary care is usually done by referral from primary or secondary medical care personnel. In
the field of sexually transmitted diseases (STDs), referral also means the informing of a partner
of a patient diagnosed STD of the potential exposure. Patient referral is where patients directly
inform their partners of their exposure to infection. An alternative is provider referral, where
trained health department personnel locate partners on the basis of the names, descriptions, and
addresses provided by the patient to inform the partner.

Essential Doctor Referral Marketing Strategies

A dangerous tendency for some medical practicesproviders that are primarily fueled by
referrals from doctorsis to believe they dont need to attract new patients..
The three circumstances that most commonly strangle referral-reliant providers are:
Benign neglect- When the referral stream is flowing, and it seems that inbound patients arrive at
your doorstep automatically, the entire organization can neglect both process and referring
physicians.

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No customer service plan- From a marketing strategy perspective, the customers are the
referring physicians and practices. And this audience requires continuous and proactive attention.
Increased competition- The constant re-invention of health care is a shifting competitive
landscape. Groups are absorbing practices, medical groups are becoming super groups, and both
are rolling up to hospitals and health systems.
Folklore has it that doctor-to-doctor referrals follow golf course rapport, lunchroom connections,
occasional hallway conversations, medical school alums, and the like. If there ever was such a
time, they evaporated long ago.
The essential requirements of an effective doctor referral marketing strategy are not casual or
incidental; they are diligent and business savvy. To maintain and grow professional referrals one
must:
1. Use a business development system
The key is having a systematic method that identifies present and prospective referral
sources, establishes and maintains a business relationship, constantly monitors and
measures the referral process, guards against competitive erosion, routinely improves
service, resolves problems quickly, expands your referral base, and regularly produces
timely management reports.
2. Organize around a robust relationship database
If your system is digging deep enough to get it right, you will probably want to use a
Customer Relationship Management (CRM) or Physician Relationship Management
(PRM) software. This sort of tool not only tracks people particulars, it provides
provider organizations with an awareness of referral activity, tabulates cases and revenue,
and frequency of contacts and correspondence of your liaison/representative.
3. If one does not have a physician liaison, the competition probably does
The traditional healthcare-referral environment has been turned on its ear. Doctors are too
busy to actively and accurately maintain dozens (perhaps hundreds) of referral source
contacts. Consequently, theres a growing demand for experienced people to call on
doctors offices, maintain relationships, and thereby inspire referrals into the practice. The
successful representativesomeone whose work brings more business in the doorwill
be a combination of the right hire, the right training, the right measures of performance
and the right supervision. Actively engaged relationships are the engine of doctor referral
building.

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 4. Effective referral marketing
For effective referral marketing, listen for what your customer tells you they need from
you that gives them confidence in continuing to refer.
5. Building service plan
Providing prompt appointments for referred patients, brief (or detailed) reports about
patient care, confirmation calls, or whatever the constituent doctors tell that they value in
a referral relationship.
6. Establish tracking and reporting for measurable goals
An effective program will prove its worth when measured by specific goals and
objectives. Its important to be clear about the intended (specific and quantifiable) results,
such as increasing physician referrals by x-amount in x-period of time. Regular
progress reports, typically monthly, will reveal effectiveness, what works and what
doesnt, and guide periodic adjustments.
The essential doctor referral marketing strategies are all intended to support a proactive system
that establishes, maintains and extends relationship, and assures a continuing stream of
professional referrals.

Marketing for International Business

The Marketing, strategy and international business group's research is focused on marketing
management and strategy, international marketing, consumer research, international business,
entrepreneurship and innovation, corporate social responsibility and sustainability strategies.
The main areas of marketing management and strategy research are:
pricing strategy
relations between marketing and sales
measurement and antecedents of environmental uncertainty
mail survey research
ethical decision-making in consumption and business practice
corporate social responsibility
marketing concepts and strategies in the service sector and in non-profit organizations
brand identification in Higher Education

The main areas of international marketing research are:

implementation of international advertising campaigns

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 regionalization of marketing standardization strategies

Ways to improve International marketing strategy

Find out if the product will travel
Many UK firms get occasional orders from overseas - thanks to the reach of the internet. But
should one actively market your products abroad? Not every product travels well so if there is
plan to expand into new territories, find out if the product can be sold widely without having to
be adapted.
Research new territories
The experience and the resources one has built up in the UK means that there is no starting from
the scratch. But there is a need to know how to leverage them appropriately - and that means
researching new markets and thinking about issues such as logistics, order fulfillment and
customer service.
Assess the size of the market
How big is the market for the product in other countries? It is to be seen how established it is,
how many players there are in that sector and how big the customer base could be. Are there any
potential trade barriers or restrictions?
Adapt the marketing strategy
One may have a product that can easily cross borders but the marketing strategy will have to be
adapted. Local values, customs, language and currencies will all impact on the marketing plan.
Look at the unique selling points and the branding. Are they right for the new markets which are
being targeted?
Work with local partners
Working with affiliates, partners, distributors, licensees or agents can help in getting a new
market established. Close consultation with business partners on the ground will ensure that the
marketing materials have local appeal and don't include any mistakes.
Check your prices
Pricing is not just about understanding currency differences - One needs to research price levels
in each new territory. The overheads may also be higher so ensure that the prices being taken into
account the cost of freight and transport, packaging and agent's commission.

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Adjusting media mix
The marketing channels which will be used will vary in each territory. In some countries, one
may rely mostly on social media or online advertising. In other places, it could be local
newspapers, outdoor advertising or radio.
Learning local customs
When it comes to customer service, what works in one country may not work in another due to
cultural differences, language and health and safety regulations. Levels of formality, business
etiquette, the way one addresses - all these are issues that could make or break the expansion
plans.
Get the timing right
Timing is everything. In some places, what is sold may be ahead of its time, in others it could be
seen as outdated. Is demand for the type of product already peaking? Or is it just starting to
grow?
Exhibit overseas
Taking a stand at trade shows abroad is a good way of dipping your toe in the water, meeting
contacts and making the first sales in a new market. It's also a chance to see what the competitors
are doing.

International Market Entry Options

Exporting
Contracting
Strategic Alliances
Joint Venture

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 Fig 1. International market entry options

Technology & Consultation

In management, information technology consulting as a field of activity focuses on advising
organizations on how best to use information technology (IT) in achieving their business
objectives. In addition to providing advice, IT consultancies often estimate, manage, implement,
deploy, and administer IT systems on behalf of their client organizations - a practice known as
"outsourcing".
The IT consulting industry can be viewed as a Four-tier system:
Professional services firms which maintain large professional workforces and command
high bill rates.
Staffing firms, which place technologists with businesses on a temporary basis, typically
in response to employee absences, temporary skill shortages and technical projects.

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 Independent consultants, who are self-employed or who function as employees of staffing
firms (for US tax purposes, employed on Form W-2), or as independent contractors in
their own right (for US tax purposes, on "1099").
Information Technology security consultants

As mobile platforms become more user friendly, computationally powerful, and readily
available, innovators have begun to develop mobile apps of increasing complexity to leverage
the portability mobile platforms can offer. Some of these new mobile apps are specifically
targeted to assisting individuals in their own health and wellness management. Other mobile
apps are targeted to healthcare providers as tools to improve and facilitate the delivery of patient
care. The FDA (Food & Drug Administration Staff) has previously clarified that when stand-
alone software is used to analyze medical device data, it has traditionally been regulated as an
accessory to a medical device or as medical device software.
According to guidelines that have been developed by the Medical Board of Australia under s. 39
of the Health Practitioner Regulation National Law Act (the National Law) as in force in each
state and territory, these guidelines aim to inform registered medical practitioners and the
community about the Boards expectations of medical practitioners who participate in
technology-based patient consultations.
These guidelines complement Good Medical Practice: A Code of Conduct for Doctors in
Australia (Good Medical Practice) and provide specific guidance on technology-based patient
consultations. The Medical Board of Australia expects medical practitioners to apply the
principles contained in Good Medical Practice, and these guidelines, when they consult a patient
outside the traditional face-to-face setting.
These guidelines are relevant to:
Medical practitioners registered under the National Law
Employers of medical practitioners
Patients and the community
Technology-based patient consultations are patient consultations that use any form of technology,
including, but not restricted to videoconferencing, internet and telephone, as an alternative to
face-to-face consultations.

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Standards of Patient Care Good
A Medical Practice describes what is expected of all doctors registered to practice medicine in
Australia. It sets out the principles that characterize good medical practice and makes explicit the
standards of ethical and professional conduct expected of doctors by their professional peers and
the community. Good Medical Practice was developed following wide ranging consultation with
the medical profession and the community. Good Medical Practice is addressed to doctors and is
also intended to let the community know what they can expect from doctors. The application of
Good Medical Practice will vary according to individual circumstances, but the principles should
not be compromised.

Providing technology-based patient consultations

Medical practitioners who advise or treat patients in technology-based patient consultations
should:
1. Apply the usual principles for obtaining their patients informed consent, protecting their
patients privacy and protecting their patients rights to confidentially
2. Make a judgment about the appropriateness of a technology-based patient consultation and in
particular, whether a direct physical examination is necessary
3. Make their identity known to the patient
4. Confirm to their satisfaction the identity of the patient at each consultation. Doctors should be
aware that it may be difficult to ensure unequivocal verification of the identity of the patient in
these circumstances
5. Provide an explanation to the patient of the particular process involved in the technology-
based patient consultation
6. Assess the patients condition, based on the history and clinical signs and appropriate
examination
7. Ensure they communicate with the patient to:
establish the patients current medical condition and past medical history, and current or
recent use of medications, including non-prescription medications
identify the likely cause of the patients condition
ensure that there is sufficient clinical justification for the proposed treatment
ensure that the proposed treatment is not contra-indicated. This particularly applies to
technology-based consultations when the practitioner has no prior knowledge or

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 understanding of the patients condition(s) and medical history or access to their medical
records
8. Accept ultimate responsibility for evaluating information used in assessment and treatment,
Irrespective of its source. This applies to information gathered by a third party who may have
taken a history from, or examined, the patient
9. Make appropriate arrangements to follow the progress of the patient and inform the patients
general practitioner or other relevant practitioners
10. Keep an appropriate record of the consultation

Face to face with the future of remote medical consultations

It's an old futurological dream. Telemedicine made its public debut in 1924, when Radio News
magazine illustrated a doctor examining his patient on a radio set equipped with a screen. In the
1950s, the University of Nebraska began experiments on medical consultations over CCTV; in
the 1960s, Nasa sponsored telemedicine for Native American communities as well as astronauts
to demonstrate the spinoff benefits of space travel.

In the 1990s, tumbling hardware prices and digital communications generated a wave of interest,
especially in countries with scattered populations such as Norway. However, unless you count
the speech-only NHS Direct service (NHS 24 in Scotland), telemedicine has found few uses in
the UK. Even when doctors accept the technology, in a small country with a comprehensive
health service it usually makes more sense to transport the patient to a doctor than to set up a
video link. For obvious reasons, the main centers of NHS interest are in Wales and Scotland,
where telemedicine has proved useful in linking patients in remote areas to specialists such as
dermatologists. What's new about the Aberdeen trial is that it tests the use of telemedicine for a
whole range of GP and A&E consultations.

Gordon Peterkin, director of the Scottish Centre for Telehealth in Aberdeen, says that a new
swathe of pressures on the NHS, from new contracts for doctors to the green agenda, mean
telemedicine time has come. The enabling technology is telepresence, a video conferencing
system which presents a life-size high-definition image of the other party as if they were sitting
just across the table. The patient's booth includes medical devices - such as a stethoscope, blood-

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pressure cuff and thermometer - to transmit essential information to the doctor. Crucially, the
whole setup works on a standard network, which means it can be deployed everywhere there is
broadband: it needs about 3.5 megabits per second.

Cisco is promoting the package globally under the brand name Health Presence. It provided
hardware for the Aberdeen trial, and is funding half of the 30,000 evaluation. (It also paid for
the Guardian, and three other publications, to attend a press demonstration last week.)
The experience is uncannily close to life - when talking to a doctor through the system I found
myself reacting automatically to her body language, edging back when she leaned too close. Real
patients seem to agree. "It was just like a normal consultation," says Urquhart.

However, a large number of questions need to be resolved before teleconsultations with family
doctors become routine. The immediate purpose of the Aberdeen trial is to check whether
teleconsultations are as effective as face-to-face ones. Despite the long history of such pilots,
Peterkin says there is a dearth of hard data of the kind that would be required for other medical
innovations.
At Aberdeen, patients who volunteer for teleconsultations in the hospital (the doctor is just down
the corridor) also receive face-to-face examinations. About 30 patients have been through the
trial and so far there have been no differences in diagnosis, according to James Ferguson, an
A&E consultant.

The trial will need about 300 patients to get a statistically significant sample.
The next stage will be to move the patient booth to a "remote safe site", probably a community
hospital, where hands-on medical help is available. If that works, the booth could go almost
anywhere. "We might put it in a hotel, or a police station," Peterkin says.

The booths could be shared with other public services, such as social security benefits. Self-
service booths are unlikely, however - the plan is that a trained attendant will help patients with
medical devices and point a handheld camera where needed.

Technology in the Traditional Learning Environment

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As computer and communications technologies are incorporated as teaching tools, traditional
materials and technologies are being adapted. Histology and pathology slides that previously
required a microscope are now digitized for study on a computer. Course management software
has become integral for both on-campus and distance learning classes due to its ability to
organize syllabi, lecture materials, handouts, and assignments.

Physicians and medical students at a clinical rotation may soon be able to attend on-campus
seminars or lectures from a laptop across town, across the state, or across the country. Telehealth
programs designed to improve medical education for students in rural healthcare areas are
developing rotations that link several community hospitals with a sponsoring medical school.

Distance learning is still in its infancy with little standardization, but most academic medical
centers have or are planning some type of distance learning programs. The availability of
technical support for both instructors and students is a critical issue for all technology-mediated
learning.

Clinical Services: Digital Delivery

Telehealth can improve access to healthcare. The initial thrust of telemedicine has focused on
linking primary care physicians with medical specialists located at distant sites and is being
utilized by health providers in a growing number of medical specialties (including dermatology,
oncology, radiology, surgery, cardiology, and psychiatry). Benefits include:

Improved access and faster diagnosis and treatment

Improved quality of care through increased consultation and collaboration and increased
patient involvement
Reduced professional isolation and the promotion of collaborative consultation
partnerships
Reduced costs from the centralization of resources, reduced travel, and the avoidance of
the duplication of services

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Asynchronous Healthcare Delivery

As in e-learning, telemedicine applications may use either asynchronous formats or interactive

systems; the selection of the technology depends on the specific application. Asynchronous
formats are used for medical consultations that do not require direct patient-doctor interaction.
Email, for example, is usually one of the first applications physicians utilize to support clinical
services and facilitates communications when physicians' schedules make them difficult to reach.
Email is used to respond to patients' questions, enhance patient education, augment screening
programs, and improve adherence to treatment protocols.

Linking patients and physicians increases the patient's involvement with his or her own
healthcare. However, certain types of information are more suited to email than others: follow-
up, specific questions and prevention education have been shown to be beneficial. Email should
not be used to convey abnormal or confusing medical test results or bad news, or for making
many diagnoses.

Some individual physicians have adopted email to communicate with patients, but most
physicians still believe it will be too time consuming. Contrary to nearly every national survey,
most physicians believe that the vast majority of their patients have no interest in communicating
with them online and greatly underestimate their patients' Internet use.

Preliminary studies show that emails for prescription refills and specific questions are an
effective way for patients and physicians to communicate. Answering an email usually takes less
time than a phone call and can be done at any time of the day. However, patient confidentiality
and reimbursement remain issues for most email situations, and those patients with access to
computers are not likely to be the underserved community who may have limited income.

Store-and-forward systems used for asynchronous telemedicine are capable of transferring

images, video or audio clips, medical records, and large data files from one location to another.

This is particularly valuable for pathology and radiology. Store-and-forward systems may be as
simple as a personal or laptop computer fitted with a modem; however, the computer must have
sufficient memory and connections to high-bandwidth systems capable of handling images and
other large files. More complex systems are optimized for specific telemedicine applications.

Synchronous/Interactive Healthcare Delivery

With interactive telemedicine the physician can interact in real-time with a patient at a remote
location through videoconferencing and technology-enabled medical instrumentation. Physical
examinations are performed using portable video units fitted with special scopes that capture
images and other information, which are then transmitted to a major medical center to facilitate
diagnosis and follow-up car.

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More sophisticated systems allow the physician to access electronic patient records while
continuing to interact with the patient. Such systems also store information from the current
session for later review or for tracking patient progress. Interactive systems may be built onto a
personal computer, which runs the medical record software and integrates videoconferencing and
file transfer capabilities.

While there are many applications across the spectrum of medical practices, the following
clinical settings commonly employ one or a combination of telemedicine technologies: home
healthcare settings, rural clinics and community hospitals, and geographically dispersed
physicians conducting clinical research.

Home Healthcare

Home healthcare has become one of the fastest growing healthcare segments using telemedicine
to supplement in-person care . In addition to videoconferencing technologies allowing long-
distance consultations, applications are available to continuously monitor vital signs and results
of home tests that can be transmitted to physicians and healthcare facilities. The 1998 edition of
the American Medical Association's Guidelines for the Medical Management of Home Care
Patients includes a section that addresses telemedicine applications and new technological
applications for home healthcare.

Accessibility of Health Information

The Internet has opened access to vast amounts of information, for both the physician and the
patient (Table 1). In the last 8 years, several federal agencies have developed health-related web
sites, many with search engines to assist both health professionals and the general public (Table
2). The National Library of Medicine web site has several searchable databases that cover the
medical literature providing citations and abstracts. The Centers for Disease Control and
Prevention has its prevention guidelines online; the Occupational Safety and Health
Administration lists requirements for medical surveillance for work-related exposures; the
National Cancer Institute has a range of prevention and research findings available online. Most
of these web sites also have databases specifically targeting the general public.

Table 1. Selected Internet telehealth resources.

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Table 2. Examples of federal agencies' health information web sites

Web sites of prominent academic health science centers offer resources ranging from excellent,
extensive information for patients to meager postings. Other health-oriented web sites offer
health education and prevention information, sell pharmaceuticals or other products, and provide
medical opinions for a fee.

A proliferation of disease-oriented web sites with chat rooms and discussion boards serve as a
way for individuals to exchange information about many serious diseases. These web sites may
serve as support groups; however, anecdotal and unsubstantiated information is frequently
proliferated.

The overwhelming volume of information that is available on the Internet makes it difficult to
determine the quality, accuracy, and authenticity of the web site. Recent surveys have shown that

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patients are most comfortable with Internet resources provided by their own physicians or local
health centers.

Rural Clinics and Health Centers

The linking of rural clinics with partner medical centers to support telemedicine and Telehealth
applications is expanding. This is of great significance to the 61 million Americans living in rural
areas, 15% of whom are elderly and prone to the chronic diseases that telemedicine is aptly
suited to manage. The National Library of Medicine-funded web page, the Telemedicine
Information Exchange lists examples of telemedicine applications and innovative uses of
technology. In a common example, emergency services across the country are improving through
the transmission of images to key medical centers for long distance evaluation/triage by
appropriate medical specialists.

In the United States, telemedicine is more common among large state-supported academic
medical centers, which are charged with providing access to medical care for patients throughout
their states. Partnerships are currently developed based on individual relationships; however,
once the capability is built and personnel are trained, networks will expand.

Web sites of prominent academic health science centers offer resources ranging from excellent,
extensive information for patients to meager postings. Other health-oriented web sites offer
health education and prevention information, sell pharmaceuticals or other products, and provide
medical opinions for a fee.

A proliferation of disease-oriented web sites with chat rooms and discussion boards serve as a
way for individuals to exchange information about many serious diseases. These web sites may
serve as support groups; however, anecdotal and unsubstantiated information is frequently
proliferated.

The overwhelming volume of information that is available on the Internet makes it difficult to
determine the quality, accuracy, and authenticity of the web site. Recent surveys have shown that
patients are most comfortable with Internet resources provided by their own physicians or local
health centers.

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Fig 2. A rural Clinic

Geographically Separated Physicians and Health Centers

Telemedicine is eliminating the boundaries of healthcare globally. In Great Britain, ophthalmic

pathology is being linked to create telepathology consultation services. In Germany, the
International Union against Cancer (ICC) launched the Telepathology Consultation Center
(TPCC) to facilitate and standardize the procedure for telepathology for tumor diagnostics and to
integrate quality and ethical standards. The TPCC is providing telepathology services via the
Internet to developing countries and smaller institutes of pathology in Eastern and Western
Europe, Asia, Africa, and North and Latin America. Telemedicine is used in Mexico, Georgia,
and Sweden to decrease the obstacle of geographical isolation to timely and quality medical care.

Healthcare Management and Administration

With instant communication and data access, distance is minimized as a factor in healthcare.
Accessing and retrieving medical records and information from medical libraries are facilitated,
as well as communication among and between patients and healthcare professionals. Integrated
clinical management systems manage patients with chronic diseases, such as diabetes and
hypertension. Such systems provide an efficient way to integrate patient education, follow-up
with nurse practitioners, nutritional counseling and support, and consultations with social
workers, as well as facilitate the monitoring of patient progress with personal profiling and data
tracking.

Medical informatics is growing to provide systems to handle the volume of medical knowledge
available through communication systems. The wide scope of informatics includes the design of
decision systems for practitioners, the development of computer tools for research, the
management and integration of clinical care, and the collection of data for evidenced based
research.

Administrative functions can be interfaced with the clinical management of a patient, providing
practitioners with the ability to better organize their services. Systems may include patient
education, scheduling capability, electronic prescribing and refills, referrals and authorizations,

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consultations, clinical trial management, online forms, insurance claims, medical supply sales,
and continuing medical education.

Developing Telemedicine Standards and Regulations

In spite of the progress that has been made, several major barriers exist and must be resolved
before the delivery of clinical services using telemedicine can become standard practice.
Tensions between privacy advocates and commercial healthcare interests regarding the practice
of telemedicine are being addressed by several national committees in federal agencies and
professional groups.

Digital Technology Overview

Three factors are driving the development of Telehealth applications: the digitization of
information, the migration toward wireless communications, and the globalization of services.
The digitization of all types of medical information makes it available for transmission and
exchange. Digital compression technology allows vast amounts of information to be stored. The
desktop computers common in most offices and many homes are being supplemented with and
may even be supplanted by wireless technologies, which are now more common in telemetry and
emergency medical services.
As digital wireless phone systems and technologies become more readily available, hand held
devices are freeing physicians from fixed computer locations and allowing instant access to
stored information and the exchange of information locally within a building, across a region, or
across the world.

Clinical Applications

Medical instrumentation is being developed to facilitate telemedicine uses, such as diagnostic-

quality stethoscopes that capture and digitize the full range of audio frequencies allowing a
clinician at a remote site to hear heart and pulmonary sounds.
This allows consultations from a distance and facilitates learning. In other applications, digital
cameras capture, store, and send images and interface with medical instrumentation. The prefix
Tele is being added to more and more medical applications.
Telemammography and Tele-ophthalmology, for example, are improving primary care delivery
in underserved clinical settings.

Benefits of Application

23
Connect to top doctors instantly

Konsult app is a mobile service that lets users choose from hundreds of highly trustworthy and
licensed doctors from top medical establishments in India. Patient can receive consultations on
call and also chat and securely share medical records with their doctors. Doctors set their own
availability and charges.

Indias number #1 Tele-consultation platform

Konsult connects you with your doctor using your phone from the comfort of your home. It is the
fastest and most cost-effective way to connect with your doctor. A belief that patients recover
faster at home which is why Konsult brings trusted specialized doctors to you. To avoid waiting
at doctors clinic or booking appointments or waiting for long OPD line, simply download
Konsult App and access quality healthcare from the comfort of your home.

They provide trustworthy doctors on their panel ranging from Psychiatrist, Dentist, Sexologist,
Cardiologist, Gynecologist, General Physician, Pediatrician, Neurologist, Urologist, ENT
Specialist, Dermatologist, Ayurveda Consultants to Dietitians to many more.

Access quality healthcare remotely

India has world class medical establishments and facilities which cater to not only local but also
out-station and international patients. However, remote access to doctors during and after the
treatment remains a problem.

Konsult allows patients to remotely connect to their doctors from both within India and abroad
from the comfort of their homes. It also allows users to exchange medical reports and
documentation through in-built chatting mechanism.

International Patient Services

Konsult also provides end to end services to international patients travelling to India from the
pre-treatment stage to the post-consultation follow-up care. They help the patients in identifying
the right doctor/hospital for their medical requirements, arrange for their travel and
accommodation, help with the appointments, and also provide interpreter services.

Pre-visit planning stage

Konsults involvement starts much earlier than the patients visit for treatment to India.
Whenever, a patient reaches out or shows an interest in a availing a medical procedure in
India The support team first contacts the patient and / or the attendants to understand
the medical history, diagnosis, current treatment, previously undergone medical
procedures etc. Thereafter, the patient is requested to provide the necessary copies of
medical documentation, which are treated as confidential and kept safe. In consultation
with the Konsults team of expert doctors, a treatment plan is prepared and also the cost

24
 of treatment is estimated.
This information is communicated to the patient so that he can make up his mind. Once
the line of treatment is accepted, they also try to arrange a pre-travel video consultation
with the specialist doctor who will be treating the patient in India.
Then a letter of invitation is arranges from the concerned hospital and assist the patient in
obtaining a medical visa for the trip to India. Prior to the patients travel, the support and
travel team arranges for suitable accommodation in the vicinity of the treatment center
and helps with flight tickets and other logistics. The patient is then all set to travel to
India.
Treatment and logistics in India
Upon the patients arrival in India An arrangement for airport pick up is made to take
the patient and his attendants to the chosen accommodation. An effort is made to make
the patient as comfortable as possible and the patients are always requested to inform
Konsult in advance if they have any special requirements.
The patient and their attendants are given an orientation regarding the travel routes,
places to eat, shop etc. Prior to the patients visit to the hospital, the team books the
necessary appointment and arranges for local transport. The in-house doctors and their
team regularly interact with hospital management on behalf of the patient and are always
available in case of any need during and after the treatment
Continued service after patient returns home
After the treatment is over and the patient is desirous of returning home, the team
configures the patients smartphone with the proprietary mobile application which can be
used by the patient and / or his attendant to stay connected to the doctor who was in-
charge the treatment in India. The team sees the patient off at the airport. They continue
to be in-touch with the patient after arrival in their home countries in case any co-
ordination is required.
At this stage the patients can use the Konsult mobile app to connect to their doctors
directly without any intervention and can discuss the progress or any follow up queries.
They can also share their test reports with the doctor directly from the mobile app and
receive their advice. At Konsult, they understand that treatment is not a one step process,
rather it is an ongoing process and the patient needs to stay connected with his treating
physician. With this aim in mind and to solve this problem Konsult app was designed.

Konsult for Doctors

25
Doctors live a life which is unlike any other profession. Their patients implicitly depend on them
and to completely disconnect is not an option. Konsult enables doctors to stay connected to their
patients through its mobile platform. Doctors can set their own consultation charges per minute
and the patient pays automatically after the call based on its duration. It is also possible for
doctors to request medical documentation from patients and then give their advice. They are also
provided with an availability status handle which gives them control over when they want to take
calls and when they dont. Not only can they stay connected to their local and out-station patients
but also patients who travel from abroad for treatment.

Panel Hospitals

Panel includes doctors from renowned hospitals like

Medanta The Medicity

Medanta - The Medicity is one of India's largest and most prestigious multi-super
specialty medical institutes. Spread across 43 acres in Gurgaon NCR and houses 1,250
beds and over 350 critical care beds, with 45 operation theatres, the hospital was founded
in 2009 by renowned cardiovascular and cardiothoracic surgeon, Dr. Naresh Trehan and
is located in Gurgaon, which is part of the National Capital Region. Primarily known as
an institute specializing in cardiology, presently Medanta has 32 institutions, departments
and division that cater to over 20 specialties. Adhering to NABH standards, the hospital is
as of 2013 accredited by ISQua (International Society for Quality in Healthcare), NABL,
and JCI.
Max Hospitals
Max Healthcare Institute is a healthcare institute based in New Delhi, India. The institute
operates eleven centers in Delhi, NCR and neighboring Punjab region, providing health
care services in more than 30 disciplines. The company provides patient services
including nuclear medicine and cardiac imaging, labs, scans, interventional cardiology,
cardiac pacing and electrophysiology, neurosciences, orthopedics, gynecology and
obstetrics, pediatrics, cancer care, kidney transplant, bone marrow transplant, maternity
services, diagnostic services, pediatric ophthalmology, neurophthalmology, internal
medicine, general surgery, urology, nephrology, gastroenterology, mental health and
behavioral sciences, rehabilitative services, and pulmonology
Fortis Hospitals
Fortis Healthcare Limited is a leading integrated healthcare delivery service provider in
India. The healthcare verticals of the company primarily comprise hospitals, diagnostics
and day care specialty facilities. The company operates its healthcare delivery services in
India, Dubai, Mauritius and Sri Lanka with 54 healthcare facilities (including projects
under development), approximately 10,000 potential beds and 260 diagnostic centres. In
a global study of the 30 most technologically advanced hospitals in the world, its

26
 flagship, the Fortis Memorial Research Institute (FMRI), was ranked No.2, by
topmastersinhealthcare.com, and placed ahead of many other outstanding medical
institutions in the world.
Apollo Hospitals
Apollo Hospitals is widely recognized as the pioneer of private healthcare in India, and
was the countrys first corporate hospital. The Apollo Hospitals Group, which started as a
150-bed hospital and today, operates 9215 beds across 64 hospitals. A forerunner in
integrated healthcare, Apollo has a robust presence across the healthcare spectrum. The
Group has emerged as the foremost integrated healthcare provider in Asia, with mature
group companies that specialize in insurance, pharmacy, consultancy, clinics and many
such key touch points of the ecosystem. The Apollo Group has touched the lives of over
45 million patients, from 121 countries.
Artemis Hospitals
Artemis Hospital, established in 2007, spread across 9 acres, is a 380 bed; state-of-the-art
multi-specialty hospital located in Gurgaon, India. Artemis Hospital is the first JCI and
NABH accredited hospital in Gurgaon. Designed as one of the most advanced in India,
Artemis provides a depth of expertise in the spectrum of advanced medical & surgical
interventions, comprehensive mix of inpatient and outpatient services. Artemis has put
modern technology in the hands of renowned from across the country and abroad to set
new standards in healthcare. The medical practices and procedures followed in the
hospital are research oriented and benchmarked against the best in the world. Top-notch
services, in a warm, open centric environment, clubbed with affordability, have made
Artemis one of the most revered hospitals in the country.
Paras Hospitals
Paras Hospitals, Gurgaon is the 250 bedded flag ship hospital of Paras Healthcare. It is a
state of the art multi super specialty hospital providing a complete spectrum of advanced
medical and surgical interventions with a comprehensive mix of inpatient and outpatient
services. Since its inception in 2006, Paras Hospitals has been moving forward with the
vision to provide competitive, innovative and accessible medical care to its patients. The
hospital offers around 55 super specialties under one roof and is supported by a team of
doctors of international and national repute. Paras Hospitals, Gurgaon, is also the first
NABH accredited corporate hospital of Haryana. It is also the first hospital of the region
to have a NABL accredited laboratory.

Medical scenarios throughout the world

27
"Academic medicine" might be defined as the capacity of the system for health and health care to
think, study, research, discover, evaluate, innovate, teach, learn, and improve. Accordingly, little
could be more important, particularly because new discoveries in science offer tremendous
opportunities, and emerging diseases pose huge threats. Indeed, the contribution of academic
medicine to human health over the last century has been extraordinary.
The public's and the government's greater understanding of the central importance of health to
societies has led to unprecedented scientific advances. New genetic technologies, rapid advances
in cell and molecular biology, and imaging technologies promise even more innovation and
progress. Recent investments in academic medicine, most notably in the United States and the
United Kingdom, are unparalleled.

Slowly but surely the public sector around the world realized that it could not support the cost of
academic medicine. Because medical students earn a lot of money during their professional
lifetime, why shouldn't they pay for their education? And if researchers are doing something
valuable, then shouldn't they be able to find a market for their product, assuming that sometimes
the public sector would pay them?

The movement of academic medicine almost entirely into the private sector started when more
and more medical schools became private, beginning with the most prestigious schools. In an
increasingly global market, these schools could charge high fees, pay their staff well, and
upgrade their facilities. They also invested a great deal in information and communication
technology, bringing state-of-the-art learning to their students. It meant, too, that the schools
could offer courses to students far away from their geographical base. As these schools
developed, they expanded internationally, sometimes forming alliances with other prestigious
schools but also taking over the weaker schools. Soon the best schools were operating on all five
continents. In the branches in developing countries, the medical student bodies tended to be
made up of students from both the developed world and a quota from the developing countries.

Competition was intense and was based on both cost and quality. Although those schools that
managed to improve quality while reducing costsusually through the clever use of technology
flourished, a great many medical schools disappeared. The number of students, however, grew,
and the competition for talent was intense, with schools offering generous scholarships to poor
but bright students and becoming ever more sophisticated at finding high-quality students in
deprived populations.

As in other intensely competitive markets, medical schools competed also by occupying niches.
That is, the schools offered very different kinds of courses, such as specializing in older students,
basic science, rural medicine, surgical skills, and training doctors for poor communities (in both
the country where the medical school was based and in lower- and middle-income countries).
Sometimes the students' fees were paid by governments, local communities, or the military in
order to produce physicians who met their needs. Many students attended schools in countries
other than their own. Some schools owned companies that produced and sold goods and services,

28
whereas others were subsidiaries or departments of global corporations (e.g., McDonald's
Hamburger University).

Health research was carried out almost entirely in the private sector, but in a wide range of
organizations: pharmaceutical companies, medical schools, biotechnology companies, small
companies offering a huge range of services, and charities. These companies were founded not
only by researchers but also by patients, practitioners, and others. Many of the companies
founded by academics offered complex and innovative health services. As in all businesses, to be
successful these companies had to be highly responsive to the needs of their customers, including
patients and governments. Those that were innovative, flexible, responsive, and relentlessly cost
conscious flourished, but many of them "failed." Little stigma was, however, attached to
"failure." Indeed, as in Silicon Valley, California, at the end of the twentieth century, the
experience of "failure" was seen by many as an important qualification in a leader.

The injection of more competitive pressure and the business model into academic medicine made
it not only more efficient but also more effective: research was much more relevant, and the
"know-do" gap between the development of new ideas and their introduction into practice was
dramatically shortened. Basic science was still well funded because both governments and
investors recognized the potentially high returns. Research on the health needs of poor and
marginal populations also improved because public-sector bodies concentrated their resources on
these problems, leaving the problems of the wealthier to the market.

On the negative side, applying the business model to academic medicine meant that efficiency
and effectiveness trumped equity. Academic Inc. resulted in a two-tier system, with the rich
finding it easy to pursue a career in academic medicine and the poor finding it hard to enter the
profession, despite the generous scholarships available to some. In addition, much more attention
continued to be paid to the health problems of wealthier people and countries, and the brain drain
from poor to rich countries accelerated. Innovation also suffered. Private academic medicine
enjoyed less lead time and had more direct and immediate accountability to its shareholders than
it had when it was publicly funded.

Reformation: "All Teach, Learn, Research, and Improve"

Twenty years ago there was increasing concern about the gap between academic medicine and
practice because important research results were not being implemented, too much research was
irrelevant, students were bored, and practitioners stopped learning. In some medical communities
the response was not to try to strengthen academic medicine and make it more responsive but to
abolish it and instead to bring teaching, learning, researching, and improving into the mainstream
of health care. This innovative response, though not initially welcomed, proved to be highly
successful and was copied everywhere. The century of academic medicine's estrangement ended.
Professors disappeared. The entity known as "academic medicine" was gone. Its destruction was

29
like that of the monasteries, and so this development became known as the "reformation of
academic medicine."

Teaching, learning, researching, and quality improvement all began to take place in the practice
setting, and they were everybody's business. The fiction that a single person could be competent
simultaneously in practice, teaching, research, and improvement was disproved. Instead, it was
teams that had to have all these competencies, not individuals, and substantial investments were
made to get teams to work well and to communicate to a degree rarely before seen in health care.

The teams were supported by advanced technology that provided online learning, decision
support, answers to questions that arose during practice, and access to research results. Patients
did much of the teaching and research, and all the teams included patients as well as
practitioners, students, professional researchers, and other health professionals.

Research was built around the questions that arose when doctors (and other health professionals)
and patients consulted together. The questions were collected by the National Question
Answering Service, which provided the answers using databanks of systematic reviews when
possible. The service also organized research to answer questions that were frequently asked to
which answers could be found later. Teams of different sizes and skills were assembled to
conduct research. Some of the researchers were permanently in practice, but others, particularly
basic researchers, were resident in research institutions and joined the teams as needed.

Fig 3

Kyrgyzstan

30
Officially known as The Kyrgyz Republic.
Capital & largest city- Bishkek
Government - Unitary parliamentary republic
President - Almazbek Atambayev
Prime Minister - Sooronbay Jeenbekov

Population in 2015
Kyrgyzstan 60,00,000
Bishkek (Capital) 9,37,400

2015 Estimates (Table 3)

GDP (PPP) GDP (Nominal)

Total $20.095 billion $6.650 billion
Per Capita $3,363 $1,113

Economy
Central Bank - The National Bank of the Kyrgyz Republic
Kyrgyzstan was the second poorest country in the former Soviet Union, and is today the second
poorest country in Central Asia.
Despite the backing of major Western lenders, including the International Monetary Fund (IMF),
the World Bank and the Asian Development Bank, Kyrgyzstan has had economic difficulties
following independence. The Kyrgyz economy was severely affected by the collapse of the
Soviet Union and the resulting loss of its vast market.

Current Scenario of Medical Sector in Bishkek

There are only 11 Hospitals/Clinics found in Bishkek, Kyrgyzstan, which are as follows:

Akyor Medical Center

Center of Scientific Research Orthopedic and Traumatology
Eye Microsurgery Hospital
Dental Clinic Kairos - DSCA Ltd
Family Medicine Training Center
German Kyrghyz Medical Center (GKMC)
Hospital No. 3
Medical Associates
National Center of Cardiology and Internal Medicine Mirakhinov
Neomed Diagnostic and Consultative Medical Center
President Hospital

31
If it is to be seen, there are only 11 Hospitals in operation serving to approximately 9,50,000
people, which is a very sad condition to see in this sector. Although the government has been
taking measures to improve this, there has been no such hike or an increase.

Kyrgyzstan improves its position in Doing Business 2016 ranking

Kyrgyzstan has improved its position in the international Doing Business 2016 index, ranking
67th out of 189 countries, the department of information support of the governments executive
office reported. According to it, during the year the country has risen by 35 positions: from
102nd place last year up to 67th.
The countrys performance in this rating has improved due to the ongoing reforms in the
stabilization of the macroeconomic environment, the optimization of public institutions and
improving the quality of infrastructure through the construction of new roads and rehabilitation
of existing one.

Health department of the city hall of Bishkek

Bishkek city Health Department is a structural subdivision of the Kyrgyz Ministry of Health and
the mayor of Bishkek, coordinates the activities of health institutions in the implementation of
public policies on health population in the city of Bishkek. The Department of Health is carrying
out activities on disease prevention, preservation and improvement of health of population of the
city. It protects the rights of the health of citizens. Implements state and national health care
programs for the population, the State Guarantees Program in the city of Bishkek. It conducts
activities to improve the quality of health care provided to the population of the city of Bishkek.

International School of Medicine, University of Kyrgyzstan

International School of Medicine (ISM) is an international higher educational institution is a

structural unit of IUK created to train medical specialists, conduct medical research in
cooperation with leading health centers of the country and countries of Far abroad.
ISM was established on a special resolution of the Kyrgyz Government to train doctors in line
with up-to-date programs that meet international training standards and requirements in different
regions of the world.

ISM has specialized scientific research laboratories run mostly by ISM with its partner
organizations. The clinical, biochemical, immunological, neurophysiological, bacteriological and
radiological laboratories are currently in operation.
International Cooperation of ISM is a priority in its strategy of general performance aimed to
integrate educational, scientific and medical technologies of world communities in Kyrgyzstan.

ISM initiated the establishment of Council of Recotors of Central Asian Medical Higher
Educational Institutions and Central Asian Association of Medical Universities.

32
ISM has sustainable and direct relations with medical schools of USA, Europe and CIS, which
enable to implement a series of international joint projects.

Hospitals under ISM

The National Center for Oncology under the Ministry of Health of Kyrgyz Republic.
The Kyrgyz Scientific and Research of Resorts Management and Recovery Treatment under the
Ministry of Health of Kyrgyz Republic.
Research Institute of Preventive Medicine under the Ministry of Health of Kyrgyz Republic.
The National Center for Mental Health under the Ministry of Health of Kyrgyz Republic.
The National Clinical Hospital for Infectious Diseases under the Ministry of Health of Kyrgyz
Republic
The National Pathological Anatomy Bureau under the Ministry of Health of Kyrgyz Republic
The National Skin and Sexually Transmitted Diseases Dispensary under the Ministry of Health
of Kyrgyz Republic
The Center of Family Medicine # 7 of Bishkek City
The Dental Policlinics # 2 of Bishkek City.
The Clinics for Surgery of National Hospital under the Ministry of Health of Kyrgyz Republic
The Bishkek City Gynecological Hospital # 1
The Bishkek City Clinical Hospital # 6.
The Bishkek City Clinical Hospital of Emergency for Children.

Medical Tourism in India

Medical Tourism to India has been growing over the years. India is being identified as quality
Healthcare destination for persons across the globe, which gainfully utilizes the health care
expertise and infrastructure available in the country. There has been a substantial growth in
medical tourism from Central Asian Countries to India.
Scope: India provides Medical care of international standards at comparatively low cost. Indian
health centers provide their expertise in the areas of Cosmetic Surgery, Dental care, Heart
Surgeries, Coronary Bypass, Heart Checkup, Valve replacements, Knee Replacements, Eye
surgeries, Indian traditional treatments like Ayurveda Therapies and much more, practically
covering every aspect of medicine combining modern treatments with traditional experience.

The most popular destinations have been Indraprastha Apollo Hospital and Medanta the
Medicity. The Indian Hospitals also have been organizing OPDs from time to time in Bishkek.

As per Assocham, Medical Tourism Industry in India in 2013 was worth Rs 75 billion ($ 1.25
billion) and forecasted to reach Rs 120 billion ($ 2.00 billion) by 2015 with an annual growth
rate of 25%. The number of medical tourists in 2013 stood at 250,000 and estimated to reach
320,000 by 2015.

33
Medical tourism to India from Kyrgyzstan and in general from Central Asia is on rise because of
quality treatment at affordable cost. According to a report Medical Value Travel in India by
KPMG and FICCI, India ranks among top three Medical Tourists in Asia

News Article
Fig 4

BIMTE-2016

Date: from 05-APR-16 to 07-APR-16

City: Bishkek
International exhibition on Medical tourism
Venue: Manege of the Academy of Physical Culture and Sports
Where: 97, Akhubaev street , Bishkek

About the exhibition:

Medical Tourism. BIMTE-2016 is the only specialized exhibition that offers a unique
opportunity to demonstrate and meet on one ground with diversity of directions in medical
tourism, establish business contacts expanding mutual cooperation, exchange thoughts and
discuss actual topics with professionals of the field. There will be international and local leading
tourism companies participating at the exhibition engaged in organizing treatment abroad,
childrens rehabilitation centers, clinics of plastic surgery, spas, sanatoria, recreation houses and
Wellness-centers.

34
Main thematic sections:

Spa treatment (climatic, balneological and mud resorts)

SPA and Wellness-centers
Alternative medicine
Medical services like preventive, diagnostic, rehabilitative, diagnostic, rehabilitation centers
and clinics
Children's health camps
Treatment abroad

Workshop in Kyrgyzstan by Indian hospitals

Workshop by the Indraprastha Apollo Hospital, Delhi [Bishkek, 5 April, 2015]

Two doctors from the Apollo Indraprastha Hospital, New Delhi, Dr. (Prof) Raju Vaishya,
MBBS, MS (Orthopedics) and Dr. (Prof) Sandeep Guleria, MS visited Bishkek on 5th
April 2015 and conducted OPD. 82 patients for orthopedics, 65 patients for Kidney
disease came for consultation offered free of cost.

Workshop by the Indraprastha Apollo Hospital, Delhi [Bishkek, 1 June, 2015] (VISIT OF
INDIAN DOCTORS FROM MEDANTA HOSPITAL TO KYRGYZSTAN)
More than 100 Kyrgyz cancer patients were operated in super specialty hospital Medanta
in India. The Deputy Director of Hospital of Department of Governmental and
Presidential Affairs Gulmira Baitova reported on Tuesday at a press conference in
KIRTAG that within the framework of bilateral cooperation, experts in the field of
oncology from India came to Kyrgyzstan for the fourth time. This time professor-
oncologist Ashok Vaid, neurosurgeon Kidia Rishab and Manager of clinic of Medanta
Wani Akber came to Kyrgyzstan. In the hospital of the Department of Governmental and
Presidential Affairs there is a plan to examine about 80-90 people. More than 100 citizens
of Kyrgyzstan underwent operation in one of the largest modern Indian hospital: Medanta

Workshop by the Indraprastha Apollo Hospital, Delhi [Bishkek, 2 June, 2014]

The Indraprastha Apollo Hospital, Delhi organized its first workshop Latest in health
care in Kyrgyzstan on 2 June, 2014 in Bishkek. The workshop was inaugurated by the
Ambassador of India to the Kyrgyz Republic and was attended, among other prominent
doctors of Kyrgyzstan, by Dr Gulnara Asymbekova, Head of the Clinic of Dr
Asymbekova and former Vice Prime Minister who called for establishing fruitful bilateral
medical cooperation between India and Kyrgyzstan.

Workshop by the Indraprastha Apollo Hospital, Delhi [Bishkek, 12 July, 2014]

The Indraprastha Apollo Hospital, Delhi organised its second workshop and the first Out

35
 Patient Department (OPD) service in Kyrgyzstan on 12 July, 2014 in Bishkek. The
workshop was inaugurated by the Ambassador of India to the Kyrgyz Republic and was
attended by around 50 doctors and senior specialists of Kyrgyzstan including Dr Gulnara
Asymbekova, Head of the Clinic of Dr Asymbekova. Focus was on the need to extend
affordable healthcare facilities to the patients and called upon the medical fraternity of
Kyrgyzstan and the Indraprastha Apollo Hospital to forge a durable partnership.
The highlight of the workshop was Apollos program on transplant and orthopedics. The
workshop generated lot of awareness and interest. The Indraprastha Apollo Hospital team
visited the Osh city also to study the profile of ailments and healthcare requirements.

Kenya
Demographics

Capital & largest City Nairobi

Official languages- English & Kiswahili

36
Ethinic Groups - 22% Kikuyu, 14% Luhya, 13% Luo, 12% Kalenjin, 11% Kamba,
6% Kisii, 6% Meru, 15% other African, 1% non-African
Government - Unitary presidential constitutional republic

President - Uhuru Kenyatta

Deputy President - William Ruto

Population (Table 4)

2014 Estimate 45,010,056

2009 Census 38,610,097

GDP (Table 5)

GDP (PPP) GDP (Nominal)

Total $143.051 billion $63.121 billion
Per Capita $3,245 $1,432

The capital, Nairobi, is a regional commercial hub. The economy of Kenya is the largest by GDP
in East and Central Africa. Agriculture is a major employer; the country traditionally exports tea
and coffee and has more recently begun to export fresh flowers to Europe. The service industry is
also a major economic driver.

Although Kenya is the biggest and most advanced economy in east and central Africa, and has an
affluent urban minority, it has a Human Development Index (HDI) of 0.519, ranked 145 out of
186 in the world.
The economy has seen much expansion, seen by strong performance in tourism, higher education
and telecommunications, and acceptable post-drought results in agriculture, especially the vital
tea sector.

Tourism
Kenya's services sector, which contributes 61% of GDP, is dominated by tourism. The tourism
sector has exhibited steady growth in most years since independence and by the late 1980s had
become the country's principal source of foreign exchange.

Health
Nurses treat 80% of the population who visit dispensaries, health centers and private clinics in
rural and under-served urban areas. Complicated cases are referred to clinical officers, medical
officers and medical practitioners. According to the Kenya National Bureau of Statistics, in 2011

37
there were 65,000 qualified nurses registered in the country; 8,600 clinical officers and 7,000
doctors for the population of 43 million people (These figures from official registers include
those who have died or left the profession hence the actual number of these workers may be
lower).

Despite major achievements in the health sector, Kenya still faces many challenges. The life
expectancy estimate has dropped to approximately 55 years in 2009five years below 1990
levels.
The infant mortality rate is high at approximately 44 deaths per 1,000 children in 2012. The
WHO estimated in 2011 that only 42% of births were attended by a skilled health professional.

Diseases of poverty directly correlate with a country's economic performance and wealth
distribution: Half of Kenyans live below the poverty level. Preventable diseases like malaria,
HIV/AIDS, pneumonia, diarrhea and malnutrition are the biggest burden, major child-killers, and
responsible for much morbidity; weak policies, corruption, inadequate health workers, weak
management and poor leadership in the public health sector are largely to blame. According to
2009 estimates, HIV prevalence is about 6.3% of the adult population.
However, the 2011 UNAIDS Report suggests that the HIV epidemic may be improving in
Kenya, as HIV prevalence is declining among young people (ages 1524) and pregnant women.

Kenya had an estimated 15 million cases of malaria in 2006.

The total fertility rate in Kenya is estimated to be 4.49 children per woman in 2012.
According to a 200809 survey by the Kenyan government, the total fertility rate was 4.6% and
the contraception usage rate among married women was 46%.
Maternal mortality is high, partly because of female genital mutilation, with about 27% of
women having undergone it. This practice is however on the decline as the country becomes
more modernized and the practice was also banned in the country in 2011.

Tropical diseases, especially malaria and tuberculosis, have long been a public health problem
in Kenya. In recent years, infection with the human immunodeficiency virus (HIV), which
causes acquired immune deficiency syndrome (AIDS), also has become a severe problem.

The United Nations Development Program (UNDP) claimed in 2006 that more than 16 percent
of adults in Kenya are HIV-infected. The Joint United Nations Program on HIV/AIDS
(UNAIDS) cites the much lower figure of 6.7 percent.

HIV/ AIDS in Kenya

Kenya has severe, generalized HIV epidemic, but in recent years, the country has
experienced a notable decline in HIV prevalence, attributed in part to significant

38
 behavioral change and increased access to ART (antiretroviral drugs). Adult HIV
prevalence is estimated to have fallen from 10 percent in the late 1990s to about 6.1
percent in 2005. Women face considerably higher risk of HIV infection than men, and
also experience a shorter life expectancy due to HIV/AIDS. The 7th edition of AIDS in
Kenya reports an HIV prevalence rate of eight percent in adult women and four percent in
adult men. Populations in Kenya especially at risk include injecting drug users and people
in prostitution, whose prevalence rates are estimated at 53 percent and 27 percent,
respectively. Treatment literacy is very low.

Here is a brief overview of the HIV epidemic in the country as reported by the Ministry of
Education in June 2014.

101,560 Kenyans were infected with HIV In 2013.

12,940 children, 50,530 women, and 38,090 men were infected with HIV in 2013.
1.6 million Kenyans were living with HIV in 2013.
63% of men and 80% of women know their HIV status

Fig 5

Current Status

In Kenya, 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 conditionalitys 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,

39
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 mobilize resources opt to travel abroad to countries like
India for treatment.

The Kenyan Ministry of Health published a report on June 2014 called Kenya HIV Prevention
Revolution Road Map. The road map aims to dramatically strengthen HIV prevention, with the
ultimate goal of reducing new HIV infections to zero by 2030. The following observations and
conclusions were outlined:

Sexual transmission accounts for 93.7% of all new HIV infections (MOT, 2008).
The HIV epidemic in Kenya exhibits extreme geographical and gender disparities.
National estimates and modeling indicate that 65% of new adult infections occur in nine
of the 47 Counties. There is higher prevalence among women at 7.6% compared to men
at 5.6% . There is a treatment gap of over 99,500 women and 64,900 men, in need of
ART but not currently receiving treatment. ART coverage is 77% in eligible women
compared to 80% in men.
Key populations contribute a disproportionately high number of new HIV infections
annually despite their small population size. According to the MOT 2008, although these
populations represent less than 2% of the general population, they contribute a third of all
new HIV infections. Key populations in Kenya include sex workers, men who have sex
with men (MSM) and people who inject drugs. Additionally, there are geographical
disparities in the distribution of key populations across the Counties.

Fig 6

Funding the HIV response in Kenya

40
A lot of money has been spent in Kenya in recent years to combat HIV, particularly through the
scaling up of ART. Between 2009 and 2013, external funding from donors accounted for over
70% of HIV expenditure. The Kenyan government has contributed 17% of funding with private
and household spending making up the remaining 13%. Since 2010, government spending has
remained stable (at 17%).
The cost of the HIV response in Kenya is expected to increase by 114% between 2010 and 2020
representing a funding gap of $1.75 billion. In order to plug this gap, Kenya has established a
High Level Steering Committee for Sustainable Financing, which has proposed the establishment
of an HIV and Non-Communicable Diseases Trust Fund to pool additional and private resources.

The future of HIV and AIDS in Kenya

In recent years, Kenya has made huge strides in tackling its HIV epidemic and has been
pioneering in the provision of HIV prevention, particularly the implementation of Voluntary
medical male circumcision (VMMC).
However, current efforts are not reaching all of those who need these services. As a result,
concentrated epidemics are emerging among vulnerable groups. Prevention initiatives need to
target these groups as part of wider efforts to stem the HIV epidemic in Kenya.

Health Care in Kenya

Health Care Units

Dispensaries
The government runs dispensaries across the country and are the lowest point of contact
with the public. These are run and managed by enrolled and registered nurses who are
supervised by the nursing officer at the respective health center. They provide outpatient
services for simple ailments such as common cold and flu, uncomplicated malaria and
skin conditions. Those patients who cannot be managed by the nurse are referred to the
health centers there.
Private Clinics
Most private clinics in the community are run by nurses. In 2011 there were 65,000
nurses on their council's register. A smaller number of private clinics, mostly in the urban
areas, are run by clinical officers and doctors who numbered 8,600 and 7,100 respectively
in 2011.

County hospitals
Kenya has 47 counties, each with a county hospital which is the referral point for the district
hospitals. These are regional centers which provide specialized care including intensive care and
life support and specialist consultations.

National hospitals
There are two national hospitals in Kenya, namely:

41
 Moi Teaching and Referral Hospital (MTRH)
Kenyatta National Hospital (KNH).

MRTH
Moi Teaching and Referral Hospital (MTRH) is the second National Referral Hospital in Kenya.
It is located in Eldoret, in the Rift Valley Province of Kenya. It was opened in 1917 as a cottage
hospital and it was not until the establishment of Moi University in 1984 and the subsequent
establishment of the Faculty of Health Sciences at the University that the hospital elevated from
a district hospital to a teaching and referral institution.
The hospital has an 800 bed capacity and received patients from western Kenya, parts of Eastern
Uganda, and the southern Sudan. The AMPATH Centre is connected to MTRH and the staff work
very closely together. Students from Moi University School of Medicine learn at this hospital,
and students and residents from the AMPATH Consortium institutions are also often found on the
wards learning from and teaching their Kenyan counterparts.

KNH
KNH has turned 115 years and The Hospital was built to fulfill the role of being a National
Referral and Teaching Hospital, as well as to provide medical research environment. Established
in 1901 with a bed capacity of 40, KNH became a State Corporation in 1987 with a Board of
Management and is at the apex of the referral system in the Health Sector in Kenya.
KNH has 50 wards, 22out-patient clinics, 24 theaters (16 specialized) and Accident &
Emergency Department. Out of the total bed capacity of 1800, 209 beds are for the Private Wing.
Kenyatta National Hospital in Nairobi is the oldest hospital in Kenya. Founded in 1901 with a
bed capacity of 40 as the Native Civil hospital.
Chairman Mr. Mark Bor.

Ministry of Health

The Ministry of Health has its headquarters at Afya house in Nairobi. There are two ministers:

Minister for medical services

Minister for public health
Each minister has two assistant ministers and a permanent secretary.

Private Health management organizations

42
Private companies which offer additional health cover usually including outpatient cover which
is not covered by the NHIF. They include:

AAR
Jubilee Insurance
Alexander Forbes Healthcare
Avenue Healthcare
Britam insurance

Financing

In Kenya, the primary sources of funding for healthcare are:

The public. These are government allocations from the national budget comprising about
30% of the total yearly expenditure in healthcare in the country. This also the main source
of funding for about 80% of the population that receives services from the public sector.
Private (consumers). This is the largest contributor of total healthcare funds spent in the
country at 35.9% of the total expenses. These funds serve about 20% of the population
that is able to access private healthcare services. These are mostly funded through
company or employee insurance schemes. These funds are thus not available for the
newly decentralized units.
Donors. These include funds to fight high burden diseases such as HIV, malaria and
Tuberculosis. These funds directly supplement public sector funds and contribute about
30% of the total healthcare expenditure in the country.

The health service delivery function was formally transferred to counties on August 9, 2013, and
one-third of the total devolved budget of KSh 210 Billion ($2 Billion) was earmarked for health
in the 2013/2014 budget following the transfer.

INDO-AFRICAN BUSINESS

43
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.

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.

Medical Tourism from Tanzania and Kenya has been at a rise to Indian hospitals particularly in
Mumbai. 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 centers of medical excellence in Mumbai specifically. High class 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.

There is no organized 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 organizations 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 centers such as Regency Hospital in
Dares 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 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. The provision of quality healthcare on
home ground would certainly be advantageous for the African patients as they can be in a

44
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.

RECENT NEWS

Kenya and Rwanda Are Competing to Become East Africas Medical Tourism Hub, Says
Frost & Sullivan
A diverse set of forces, including favorable economic factors, a supportive regulatory
environment, and a high disease burden will make Kenya and Rwanda among the most attractive
countries in East Africa. The consolidation of the rising middle class and heightened healthcare
awareness will drive up per capita healthcare expenditure and provide lucrative opportunities
within these markets.
New analysis from Frost & Sullivan, Health care System Development in Kenya and Rwanda
(http://www.frost.com/mac1), finds that healthcare is regarded as the fourth-most attractive
investment sector in Africa. As the East African economy continues to grow and the population
has more disposable income to afford better healthcare, the demand for specialized healthcare
services is expected to increase. However, the lack of skilled resources as reflected by the low
health worker density of 0.84 per 1000 people in Rwanda and 1.3 per 1000 people in Kenya as
well as inadequate infrastructure, need for capital investment, and high construction costs
hamper the availability of specialist care and high-end technologies in both countries.

Dracunculiasis eradication: WHO ready to verify Kenya and Sudan

Kenya: Moving towards rabies elimination

With the help of World Animal Protection, a non-governmental organization, and technical
guidance from WHO, Kenyas government launched an initiative in September 2014 to vaccinate
70% of the countrys 125 000 dogs. In Makueni County, along with targeting the immediate
threat of rabies through vaccination campaigns, World Animal Protection will educate
communities about rabies, how to avoid dog bites and what to do in case of a bite.

Kenya takes steps to save mothers lives, showing why better data matters
To help Kenya and other countries to integrate these health data systems into a unified, more
efficient framework, global health partners including WHO have formed the Health Data
Collaborative to harmonize their financial and technical resources and ensure they are in line
with country priorities. Kenya is the first country in Africa to officially launch the Health Data
Collaborative at country level.

List of Medical Tourism Companies in Kenya (Table 6)

45
Company Name Address
Pathway International 7th &2nd Floor, KMA Centre, Upperhill, Mara Road. P.O.
Box 6493-00200 Nairobi, Kenya or Rwanda Office: Kigali,
La bonne adresse building, 3rd floor, Avenue de la paix.,
Nairobi
Fortec Medix Supplies Ltd ForteC Medix Supplies Ltd

AFRICA MEDICAL Adams Arcade 1st Floor, Room No. 3 , P.O.Box 20009
OPINION 00200, Nairobi
Bc-Health Systems EA P.O BOX 29725-00100, Nairobi

PlacidWay Medical Tourism 8008 East Arapahoe Court, Suite 100 Centennial, CO,
Nairobi
LLARDS INSURANCE ICEA BUILDING KENYATTA AVENUE 17TH FLOOR
AGENCY LTD CBD, Nairobi
Top Notch Healthcare 24108- 00100, Nairobi

Med Access Africa Landmark Plaza, 13th Floor Argwings Kodhek Road, P.O.
Box 24690 00502, Nairobi

Nigeria
Demographics

46
Capital Abuja
Largest City - Lagos
Official languages- English
Government - Federal presidential republic
President - Muhammadu Buhari
Vice President Yemi Osinbajo

Population (Table 7)

2015 Estimate 182,202,000

2006 Census 140,431,790

GDP (Table 8)

GDP (PPP) GDP (Nominal)

Total $1.166 trillion $484.895 billion
Per Capita $6,351 $2,640

Nigeria is often referred to as the "Giant of Africa", owing to its large population and economy.
With approximately 184 million inhabitants, Nigeria is the most populous country in Africa and
the seventh most populous country in the world. Nigeria has one of the largest populations of
youth in the world. The country is viewed as a multinational state, as it is inhabited by over 500
ethnic groups, of which the three largest are the Hausa, Igbo and Yoruba; these ethnic groups
speak over 500 different languages, and are identified with wide variety of cultures.

Nigeria is divided roughly in half between Christians, who live mostly in the southern part of the
country, and Muslims in the northern part. A minority of the population practice religions
indigenous to Nigeria, such as those native to Igbo and Yoruba peoples.

As of 2015, Nigeria is the world's 20th largest economy, worth more than $500 billion and $1
trillion in terms of nominal GDP and purchasing power parity respectively. It overtook South
Africa to become Africa's largest economy in 2014. Also, the debt-to-GDP ratio is only 11
percent, which is 8 percent below the 2012 ratio.

Nigeria is considered to be an emerging market by the World Bank. It has been identified as a
regional power on the African continent, a middle power in international affairs, and has also
been identified as an emerging global power. Nigeria is a member of the MINT group of
countries, which are widely seen as the globe's next "BRIC-like" economies.

It is also listed among the "Next Eleven" economies set to become among the biggest in the
world. Nigeria is a founding member of the Commonwealth of Nations, the African Union,
OPEC, and the United Nations amongst other international organizations.

47
Health
Health care delivery in Nigeria is a concurrent responsibility of the three tiers of government in
the country, and the private sector. Nigeria has been reorganizing its health system since the
Bamako Initiative of 1987, which formally promoted community-based methods of increasing
accessibility of drugs and health care services to the population, in part by implementing user
fees. The new strategy dramatically increased accessibility through community-based healthcare
reform, resulting in more efficient and equitable provision of services. A comprehensive
approach strategy was extended to all areas of health care, with subsequent improvement in the
health care indicators and improvement in health care efficiency and cost.

HIV/AIDS rate in Nigeria is much lower compared to the other African nations such as Kenya or
South Africa whose prevalence (percentage) rates are in the double digits. As of 2012, the HIV
prevalence rate among adults ages 1549 was just 3.1 percent. As of 2014, life expectancy in
Nigeria is 52.62 years on average according to CIA, and just over half the population has access
to potable water and appropriate sanitation; as of 2010, the Infant mortality is 8.4 deaths per
1000 live births.

Nigeria was the only country in Africa to have never eradicated polio, which it periodically
exported to other African countries; Polio was cut 98% between 2009 and 2010. However, a
major breakthrough came in December 2014, when it was reported that Nigeria hadn't recorded a
polio case in 6 months, and on its way to be declared Polio free. In 2012, a new bone marrow
donor program was launched by the University of Nigeria to help people with leukemia,
lymphoma, or sickle cell disease to find a compatible donor for a life-saving bone marrow
transplant, which cures them of their conditions.

Nigeria became the second African country to have successfully carried out this surgery. In the
2014 Ebola outbreak, Nigeria was the first country to effectively contain and eliminate the Ebola
threat that was ravaging three other countries in the West African region, the Nigerian unique
method of contact tracing employed by Nigeria became an effective method later used by
countries such as the United States, when Ebola threats were discovered.

The Nigerian health care system is continuously faced with a shortage of doctors known as 'brain
drain', because of emigration by skilled Nigerian doctors to North America and Europe. In 1995,
it was estimated that 21,000 Nigerian doctors were practicing in the United States alone, which is
about the same as the number of doctors working in the Nigerian public service. Retaining these
expensively trained professionals has been identified as one of the goals of the government.

Nigeria makes crucial progress in eradicating polio

48
On the edge of the war zone, near the territory controlled by the murderous thugs of Boko Haram
in northern Nigeria, the hit-and-run teams waited patiently for the go-ahead from the security
forces.

When the soldiers decided the moment was right, the mobile units rushed into the war zone not
to shoot or attack, but in a frantic effort to vaccinate children against polio. A few hours later,
they rushed back to safety.

Hit-and-run immunizations are just another of the extraordinary tactics in a relentless campaign
to eradicate the polio virus from one of its last havens. Today the campaign is close to a historic
breakthrough: eliminating polio from Africa for the first time.

Nigeria, always the final barrier for African anti-polio campaigns, hasnt recorded a single new
case of the wild polio virus since July. Only six cases have been recorded in Nigeria this year a
dramatic 90-per-cent decline from last year. This is crucial progress, since Nigeria has been the
sole reservoir for the spread of the virus to dozens of other African countries. It would leave
Pakistan and Afghanistan as the only remaining countries in the world where polio is still
endemic.

With the help of foreign donors and strict new government policies supporting huge vaccination
campaigns, Nigeria is closer than ever to eliminating the potentially paralyzing disease, although
technically it must go three years without new cases before it can be declared polio-free. That
would be a major step toward the defeat of polio. It could become only the second human disease
ever to be eradicated by vaccine. (Smallpox was the first.)

While much of the world was panicked this year by the rise of Ebola, which exposed the
weaknesses of health care in some of Africas poorest countries, Ebola has obscured Africas
quieter progress on other diseases.

One of its biggest killers, malaria, has been drastically rolled back as mosquito nets are more
widely distributed and as treatment and diagnosis improve. The malaria death rate in Africa has
tumbled by 54 per cent in the past 14 years, saving the lives of about 3.9 million children,
according to new statistics this month by the World Health Organization.

Polio is another example of the progress. In fact, the success of Nigerias anti-polio efforts has
allowed some of its health workers to be shifted to the new task of fighting Ebola in Liberia and
Sierra Leone.

How did Nigeria make such gains in its polio campaign? Just a decade ago, the campaign was in
serious trouble, as northern politicians and religious leaders spread rumors that the polio vaccine
caused AIDS and infertility. In February, 2013, disaster struck again when gunmen killed nine
vaccination workers in the northern city of Kano.

49
But Nigeria has also been among the major beneficiaries of Rotary and the Gates Foundation,
which are spending billions of dollars in the fight against polio. Thousands of health teams have
fanned out across the country to vaccinate children, and governments have imposed strict rules to
demote or dismiss officials who disobey the strategy. Religious leaders have been recruited into
the campaign, ensuring that the worst rumors are dispelled.

In the past, vaccination teams would sometimes claim to have vaccinated far more children than
they actually did. Under the new system, they must carry satellite devices so their movements
can be tracked and mapped by a co-ordination center as they work. If they miss a remote village,
they are sent back to do it. They vaccinate children in front of their homes, rather than inside, so
their work can be easily monitored by supervisors. Even nomadic cattle-herding families are
tracked down and vaccinated.

As the situation improves in Nigeria, the spotlight is shifting to the two other countries where
polio is still endemic: Pakistan and Afghanistan. After the CIA used a fake vaccination campaign
to search for Osama bin Laden in 2011, militants in Pakistan have killed dozens of anti-polio
workers, and the number of polio cases has jumped to its highest level in two decades.

New cases have also emerged in Syria and Iraq this year as a result of the Pakistan outbreak. And
in Africa, scattered cases have occurred in Cameroon, Equatorial Guinea, Somalia, Ethiopia,
South Sudan and Madagascar. But no cases of the wild polio virus have been reported anywhere
in Africa since August.

Despite the progress, theres no room for complacency, especially with Nigerian politicians
distracted by national elections in February, experts say. Previous elections in Nigeria have led to
resurgences of polio.

Recent News
Nigeria Boko Haram: Children starving, warns Unicef
Almost a quarter of a million children in parts of Nigeria's Borno state formerly controlled by
Boko Haram are suffering from severe malnutrition, the UN children's agency says. Tens of
thousands will die if treatment does not reach them soon, UNICEF warns.

In areas where Boko Haram militants had been in control, it found people without water, food or
sanitation. Last month, a charity said people fleeing Boko Haram had starved to death. The
Islamist group's seven-year rebellion has left 20,000 people dead and more than two million
displaced. Nigeria's military is involved in a large-scale offensive against the group.

UNICEF says that as more areas in north-eastern Nigeria become accessible to humanitarian
help, the extent of the nutrition crisis affecting children is becoming more apparent. It said that of
the 244,000 children found to be suffering from severe acute malnutrition in Borno, almost one
in five would die if they were not reached with treatment.

50
"Some 134 children on average will die every day from causes linked to acute malnutrition if the
response is not scaled up quickly," said Manuel Fontaine, UNICEF's Regional Director for
Western and Central Africa. "We need all partners and donors to step forward to prevent any
more children from dying. No-one can take on a crisis of this scale alone."

Mr Fontaine said he had seen destroyed towns accommodating displaced people and thousands
of frail children in desperate need of help. "There are two million people we are still not able to
reach in Borno state, which means that the true scope of this crisis has yet to be revealed to the
world," he added.

"There are organizations on the ground doing great work, but none of us are able to work at the
scale and quality that we need. We must all scale up." MSF said in June that a "catastrophic
humanitarian emergency" was unfolding at one camp in Bama, Borno state, where 24,000 people
had taken refuge. Many inhabitants were traumatized and one in five children was suffering from
acute malnutrition, it said.

UNICEF helps thousands of displaced people at its clinics in Borno state. (Fig 7)

51
Democratic Republic of the Congo
Demographics

Capital & largest City Kinshasa

Official languages- French
Government - Unitary semi-presidential republic
President - Joseph Kabila
Prime Minister Augustin Matata Ponyo

Population (Table 9)

2015 Estimate 81,680,000

GDP (Table 10)

GDP (PPP) GDP (Nominal)

Total $68.691 billion $42.056 billion
Per Capita $816 $499

Health
The Democratic Republic of Congo is extremely rich in natural resources, but political
instability, a lack of infrastructure, deep rooted corruption, and centuries of both commercial and
colonial extraction and exploitation have limited holistic development. Besides the capital,
Kinshasa, the other major cities, Lubumbashi and Mbuji-Mayi, are both mining communities.
DR Congo's largest export is raw minerals, with China accepting over 50% of DRC's exports in
2012. As of 2013, according to the Human Development Index (HDI), DR Congo has a low level
of human development, ranking 176 out of 187 countries.

The hospitals in the Democratic Republic of the Congo include the General Hospital of
Kinshasa. DRC has the world's second-highest rate of infant mortality (after Chad). In April
2011, through aid from Global Alliance for Vaccines, a new vaccine to prevent pneumococcal
disease was introduced around Kinshasa.

In 2012, it was estimated that about 1.1% of adults aged 1549 were living with HIV/AIDS.
Malaria is also a problem. Yellow fever also affects DRC. Maternal health is poor in DRC.
According to 2010 estimates, DRC has the 17th highest maternal mortality rate in the world.
According to UNICEF, 43.5% of children under five are stunted

52
Migration
Given the situation in the country and the condition of state structures, it is extremely difficult to
obtain reliable data. However, evidence suggests that DRC continues to be a destination country
for immigrants in spite of recent declines. Immigration is seen to be very diverse in nature, with
refugees and asylum-seekers products of the numerous and violent conflicts in the Great Lakes
Region constituting an important subset of the population in the country. Additionally, the
country's large mine operations attract migrant workers from Africa and beyond and there is
considerable migration for commercial activities from other African countries and the rest of the
world, but these movements are not well studied.

Transit migration towards South Africa and Europe also plays a role. Immigration in the DRC
has decreased steadily over the past two decades, most likely as a result of the armed violence
that the country has experienced. According to the International Organization for Migration, the
number of immigrants in the DRC has declined from just over 1 million in 1960, to 754,000 in
1990, to 480,000 in 2005, to an estimated 445,000 in 2010. Official figures are unavailable on
migrant workers, partly due to the predominance of the informal economy in the DRC. Data are
also lacking on irregular immigrants, however given neighbouring country ethnic links to
nationals of the DRC, irregular migration is assumed to be a significant phenomenon in the
country.

Figures on the number of Congolese nationals abroad vary greatly depending on the source, from
3 to 6 million. This discrepancy is due to a lack of official, reliable data. Emigrants from the
DRC are above all long-term emigrants, the majority of which live within Africa and to a lesser
extent in Europe; 79.7% and 15.3% respectively, according to estimates on 2000 data. New
destination countries include South Africa and various points en route to Europe. The DRC has
produced a considerable number of refugees and asylum-seekers located in the region and
beyond. These numbers peaked in 2004 when, according to UNHCR, there were more than
460,000 refugees from the DRC; in 2008, Congolese refugees numbered 367,995 in total, 68% of
whom were living in other African countries. Since 2003, more than 400,000 Congolese migrants
have been expelled from Angola.

53
Recent News
The many challenges to fighting yellow fever in Democratic Republic of the Congo (Source
WHO)

The Democratic Republic of the Congo faces many challenges in responding to the yellow fever
outbreak. Access to areas along the Angolan border is extremely difficult and there is a lack of
essential resources, such as fuel to run electricity generators.

WHO is working with the government and partners to organize a mass vaccination campaign of
approximately 3 million people along the border with Angola. This photo story highlights some
of the challenges in providing health services to this remote area.

Yellow fever crosses borders

DR Congo shares its long, southern
border with Angola, stretching for more
than 2,500 kms. The two countries have
been inextricably linked for centuries and
a steady flow of people cross daily from
both sides to visit family or trade. Many
young Congolese travel to Angola to
search for work or diamonds. But the
highly porous nature of the border is
making it easier for the yellow fever
outbreak in Angola to spread to DR
Congo.

Challenges in access
One of the major challenges facing
vaccination campaigns in DR Congo
is access. Getting to the southern
parts of the country that border
Angola involves travelling hundreds
of kilometers across difficult terrain.
Roads between the numerous
villages scattered across the area
are often nothing more than forest
tracks through dense vegetation.

54
Accelerating response efforts
A joint mission from DR Congos ministry of
Health, WHO and Medicins Sans Frontieres
meets with local health authorities in Kenge,
the capital of Kwango province to assess
needs for the planned yellow fever
vaccination campaign. Later, the response
team travelled to the border areas to assess
challenges and evaluate how best to
accelerate the response to the outbreak and
prepare for mass vaccination.

Testing blood sample to treat patients

and prevent further spread
The vaccines to the border areas, WHO is
also assessing how to get blood samples out
so they can be tested. The faster blood
samples are tested, the quicker people with
yellow fever can be treated, and those
nearby can be vaccinated if the sample is
positive. In kwango province there are no
facilities to test for yellow fever and getting
samples to the lab in Kinshasa can take upto
a week. These men are transporting blood
samples for yellow fever testing in a cool box
on the back of a motorbike.

Recognizing yellow fever symptoms at

the border
Ensuring that healthcare workers at the
border recognizes the symptoms of yellow
fever and know what actions to take is key to
treating patients, tracing the outbreak and
targeting the response. At Shamaziamno, the
principle border crossing between Angola
and Kwango province.
DR Congo, nurse Nicole Tshibulenu responds
to a WHO epidermologists queries on recent

55
INDIA - A Premier Health Care Destination
Medical tourism refers to the travel of people to another country for the purpose of obtaining
medical treatment in that country. Traditionally, people would travel from less-developed
countries to major medical centers in highly developed countries for medical treatment that was
unavailable in their own communities; the recent trend is for people to travel from developed
countries to third-world countries for medical treatments because of cost consideration.

In the past few years, Asia has taken the lead as one of the most preferred destination for medical
value travel. Primary growth levers in this regard include availability of variety of treatments,
improved infrastructure in terms of health care facilities and attractive locations for spending
time after treatment. Asian countries have introduced various marketing strategies to attract
medical tourists.

Over the years, India has grown to become a top-notch destination for medical value travel
because it scores high over a range of factors that determines the overall quality of care. India
was one among a few countries to recognize the potential of medical tourism for which it is the
leading destination for global medical tourists today. In 2004, India received 150,000 medical
tourists approximately and the number went up by a whopping 33% to 200,000, inbound medical
tourists in year 2008.

In October 2015, India's medical tourism sector was estimated to be worth US$3 billion. It is
projected to grow to $7-8 billion by 2020.
According to the Confederation of Indian Industries (CII), the primary reason that attracts
medical value travel to India is cost-effectiveness, and treatment from accredited facilities at par
with developed countries at much lower cost. The Medical Tourism Market Report: 2015 found
that India was "one of the lowest cost and highest quality of all medical tourism destinations, it
offers wide variety of procedures at about one-tenth the cost of similar procedures in the United
States."

Year Foreign patients travelling to India to seek

medical treatment

2012 1,71,021
2013 2,36,898
2014 1,84,298
(Table 11)

Largest source countries for medical tourism to India:

Traditionally, United Kingdom & USA.
According to a CII-Grant Thornton report released in October 2015, Bangladeshis and Afghans
accounted for 34% of foreign patients, the maximum share, primarily due to their close
proximity with India and poor healthcare infrastructure.

56
Russia and the Commonwealth of Independent States (CIS) accounted for 30% share of
foreign medical tourist arrivals.
Other major sources of patients - Africa and the Middle East, particularly the Persian Gulf
countries.

In 2015, India became the top destination for Russians seeking medical treatment. Chennai,
Kolkata, Mumbai, Andhra Pradesh and the National Capital Region received the highest number
of foreign patients primarily from South Eastern countries.

Medical Tourism Process

A person seeking medical treatment abroad contacts a medical tourism provider, who is
commonly referred to as a "facilitator". The facilitator usually requires the patient to provide a
medical report, including the nature of ailment, local doctors opinion, medical history, and
diagnosis, and may request additional information, such as x-rays or diagnostic testing results.
Certified physicians or consultants may advise on the medical treatment or recommend an initial
consultation with a specialist. The approximate cost of treatment, the choice of doctor and
hospital, expected duration of stay, and logistical information, such as accommodation, ground
transportation, and flights are discussed as well.
A patient may be asked to pay an upfront deposit for treatment. For those destinations which
require a visa, the patient will be given recommendation letters for a medical visa for the relevant
embassy. The patient travels to the destination country, where the medical tourism provider may
assign a case executive, who takes care of on the ground experience, including translation,
accommodation, and arranging aftercare. In the cases where patients self-pay for medical
treatment, a final treatment bill will be presented upon completion of treatment. If the patient
underwent surgery, there may be additional post-operative checks to discharge the patient and
deem him or her "fit for flight" for the return home trip.

Reasons for growth of medical tourism in India

Medical tourism in India is expected to grow at the rate of 30 % in 2015 and India`s decision to
offer medical-M-visa on- arrival to citizens of 180 countries will be a big boom for the medical
tourism Industry In India.

57
Foreign Tourist Arrivals register a growth of 10.2% in 2014 over 2013 & 2012

The growth registered in the final figures of Foreign Tourist Arrivals (FTAs) in India during last
three years was better than the provisional estimates of FTAs except for the year 2012. The
provisional estimates and final figures of FTAs in India along with the growth rates over
previous year are given below:

Year 2012 2013 2014

Provisional FTAs (in 6.65 6.85 7.46
million)
Growth Rate (%) 5.4 4.1 7.1

Final FTAs (in 6.58 6.97 7.68

million)
Growth Rate (%) 4.3 5.9 10.2

- Source: Ministry of tourism, Government of India, press release dated 27-7-15. (Table 12)

Medical Tourist Arrival in India

The citizens of countries that visit India for Medical purposes are mainly from Maldives (59% of
50,000 visitors), Nigeria (29% of 37000 visitors), Iraq (33% of 39000 visitors), Afghanistan
(16% of 95000 visitors), Oman (11% of 50000 visitors), UAE (8% of 41000 visitors).

Fig 8

58
The figures indicate that foreign tourist Arrivals to India is increasing every year and similarly
the medical tourists arrival is growing by 30 % annually.

Foreign Tourists Arrivals (FTSs) to India in 2013

S.No. Source Country FTAs (in mn) % Share

1 USA 1,085,309 15.58
2 United Kingdom 809,444 11.62
3 Bangladesh 524,923 7.53
4 Sri Lanka 262,345 3.77
5 Russian Fed 259,120 3.72
6 Canada 255,222 3.66
7 Germany 252,003 3.62
8 France 248,379 3.56
9 Malaysia 242,649 3.48
10 Japan 220,283 3.16
Total of Top 10 Countries 4,159,677 59.70
Others 2,807,924 40.30
Total 6,967,601 100.0

Foreign medical tourists arrival is 2-3 % of the total FTAs. (Table 13)

Advantages of Medical Tourism in India

Reduced costs
Availability of latest medical technologies
Growing compliance on international quality standards
Foreigners are less likely to face a language barrier in India

59
Most estimates found that treatment costs in India start at around 1/10th of the price of comparable
treatment in the United States or the United Kingdom. . The cost difference is huge-open heart
surgery costs up to $ 70,000 in UK and $ 1, 50,000 in US, but in India in best hospitals it could
cost between $3000 - $10,000. Knee surgery costs around Rs 3.6 lakhs in India ($ 6000) in
Britain it costs $17,000. Dental, eye and cosmetic surgeries cost three to four times more than in
India. Medical tourist usually gets a package that includes flights, treatment, hotels and usually
post-operative vacation and rejuvenation therapies.

The most popular treatments sought in India by medical tourists are bone-marrow transplant,
cardiac bypass, eye surgery and hip replacement. India is known in particular for heart surgery,
hip resurfacing and other areas of advanced medicine. Some of the leading hospitals for medical
tourism are Apollo Hospitals, Global Hospitals, Narayana Health, Bombay Hospital, Hinduja
Hospital, Hiranandani Hospital, Akruti Institute of Plastic and Cosmetic Surgery, Columbia Asia,
and Fortis Health Care.

Despite India's diversity of languages, English is an official language and is widely spoken. In
Noida, which is fast emerging as a hotspot for medical tourism, a number of hospitals have hired
language translators to make patients from Balkan and African countries feel more comfortable
while at the same time helping in the facilitation of their treatment.

Indias Health Capital - Chennai

The city of Chennai has been termed as "India's health capital.
Multi- and super-specialty hospitals across the city bring in an estimated 150 international
patients every day. Chennai attracts about 45 percent of health tourists from abroad arriving in
the country and 30 to 40 percent of domestic health tourists.
The city has an estimated 12,500 hospital beds, of which only half is used by the city's
population with the rest being shared by patients from other states of the country and foreigners.

Government support

The government in the country is supporting this industry by assisting hospitals in acquiring the
Joint Commission International accreditations and awarding funds for renovations and additions.
The government in India is leaving no stone unturned to improve both the private and public
medical sectors in the country. The government has removed visa restrictions on tourist visas that
required a two-month gap between consecutive visits for people from Gulf countries which is
likely to boost medical tourism. A visa-on-arrival scheme for tourists from select countries has
been instituted which allows foreign nationals to stay in India for 30 days for medical reasons. A
medical visa (MED Visa) is granted to a foreigner whose sole purpose of visiting India is to seek
medical treatment in specialized/ recognized established Hospitals/treatment centers in India.

60
Risks in Medical Tourism

Medical tourism carries some risks that locally provided medical care does not. Some countries,
such as South Africa, or Thailand have very different infectious disease-related epidemiology to
Europe and North America. The quality of post-operative care can also vary dramatically,
depending on the hospital and country, and may be different from US or European standards.
Also, traveling long distances soon after surgery can increase the risk of complications.

Legal issues- Receiving medical care abroad may subject medical tourists to unfamiliar legal
issues. The limited nature of litigation in various countries is one reason for the lower cost of
care overseas. Issues can also arise for patients who seek out services that are illegal in their
home country. In this case, some countries have the jurisdiction to prosecute their citizen once
they have returned home, or in extreme cases extraterritorially arrest and prosecute.

Ethical issues- There can be major ethical issues around medical tourism. For example, the
illegal purchase of organs and tissues for transplantation had been methodically documented and
studied in countries such as India, China, Colombia and the Philippines. Medical tourism may
raise broader ethical issues for the countries in which it is promoted. For example, in India, some
argue that a "policy of 'medical tourism for the classes and health missions for the masses' will
lead to a deepening of the inequities" already embedded in the health care system.

Challenges Faced by Medical Tourism in India

(i) Commercialization of the profession is one point which some doctors are not comfortable
since the personal doctor-patient relationship will be missing.
(ii) Secondly, there is recuperation for patients who avail of treatment abroad. While cosmetic or
dental surgery might not require extensive aftercare, orthopedic or heart bypass surgery might
require the patient to be under post-treatment observation for some time, this would be best
under the doctor who has treated him and who is fully aware of his condition.
(iii) Thirdly, there is the issue of insurance cover, insurance companies in developed countries
provide cover for treatment availed of in other countries only when the standard of services is the
same as the patient`s home country. Some countries provide insurance cover only for treatment
taken in their country.
(iv) Poor power supply even to hospitals.
(v) No Industry standards followed in hospitals.
(vi) Inequalities in the medical services provided by Government and private hospitals will
increase.
(vii) Brain drain from government sector to private sector.
(viii) Increase in medical costs for local people.

61
Ayurveda

Ayurveda medicine is a system of medicine with historical roots in the Indian subcontinent.
Globalized and modernized practices derived from Ayurveda traditions are a type of
complementary or alternative medicine. he centuries-old tradition of ancient Indian Ayurveda is
fast turning Kerala into a global medical tourism destination, attracting holidayers as well as
International celebrities to the state.
According to sources in Kerala Tourism department, those who visited the state in recent times
included Italian film director Bernardo Bertolucci, who came to the state for Ayurveda treatment
for a nagging ailment. From autism to Alzheimer's, from pregnancy to weight loss, from
migraine to diabetes, from sexual disability to slip disc -- there is not a single problem that
Ayurveda does not have an answer for. Kerala Tourism has introduced the "Green Leaf" and
"Olive Leaf" grading for Ayurveda institutions in order to ensure quality service. Green Leaf is
given to those Ayurveda centers which provide 'five star' facilities while Olive Leaf is for the
'three star' category. These classifications ensure the credibility of service providers and the
quality which helps tourists to identify appropriate centers for their requirements.

More tourists are coming to India

because cost of treatment here is
much less compared to the US and
the European countries. We are also
trying to integrate medical tourism
with normal tourism, said Parvez
Dewan, secretary, ministry of
tourism, government of India.

Fig 9.

Listed below are some of the famous hospitals in India associated with Medical Tourism:

Apollo Family Health Plan, Apollo Hospitals

The establishment that Apollo Hospitals offer patients, the same level of quality treatment
at only a fraction of the global prices, led to a revolution in medical treatment in India.
Artemis Hospital
Medical Tourism Corporation facilitates medical treatment to Artemis Hospital in India &
many other world class Hospitals.
B M Birla Heart Research Center
Belle Vue Clinic Calcutta Medical Research Institute
Cancer Patients Aid Association (CPAA)
Escorts Heart Research Institute
Emmanuel Hospital Association

62
 Indraprastha Apollo Hospitals
Max Hospitals
Max has a team of highly experienced surgeons of repute lead by Dr. S. K. S. Marya. The
hospital has high quality equipment and uses the finest quality of imported and standard
implants for all procedures. The operation theaters have been made as per international
health tourism specifications using ultra-clean air exchanges and follow the highest
standards of infection control matching the best in the world. The hospital also provides
specialized physiotherapy and support services to medical travel patients.
New Delhi Institute of Dental & Orthodontic Radiography
King Edward Memorial Hospital
Lifeline Group of Hospitals
M.V.Diabetes Specialties Centre (P) Ltd.
Mansarovar Eye Hospital,Lucknow
Sir Ganga Ram Hospital
Fortis Group Of Hospitals
Surya Medical Trust Burns Center, Pune
The Advanced Medicare Research Institute Ltd.
The Eye Research Foundation - Vimhans
Wockhardt Hospital And Heart Institute
Wockhardt Ltd., the most renowned healthcare institution in India, has associated with
Harvard Medical International, USA. As associate hospitals of Harvard Medical, USA in
India, Wockhardt hospitals benefit from the extensive learning and experience of Harvard
Medical School and its affiliated institutions world-wide. This association helps
Wockhardt Hospitals to stay at the forefront of medical technology and techniques, way
ahead of others.

All these hospitals take considerable effort to make sure that their foreign patients enjoy a
trouble free stay. Some of them also have special cells to take care of international patients
and they provide all kinds of services from pick and drop from and to the airport to arranging
accommodation for the attendants. A handful of tour operators have seen that the way of the
future is medical tourism, and say they are offering med tours to tourists who are interested.
Embassy of India Kabul, Afghanistan typical med tour would offer a combination of a
therapy or treatment whether mainstream or alternate and recuperation at places of the
visitor's choice. The recuperation would often include popular tourist activities.

Healthcare and medical: International trade regulations

63
Export regulations in the healthcare and medical sector
Regulations, charges or other restrictions may apply to healthcare and medical exports as they
leave the UK and when they arrive at their destination country. Use of standardized classification
codes makes it easier to check if any restrictions or charges apply.

It is much simpler to trade with other EU countries than with countries outside the EU. This is
because the goods are in free circulation. The EU is a single market and the UK is in a customs
union, so one can trade most goods, except medicines, with other EU countries without
restriction (although some local charges may still apply).

In some countries preferential rates for export have been agreed. For instance, the EU duty on
exports of certain medical equipment is zero as a result of the Uruguay Round of Multilateral
Trade Negotiations agreed in 1994. Other countries where this deal is in force are the USA,
Canada, Japan, Australia, New Zealand and South Korea.

The European Commission has identified the need to secure supply chains for goods leaving and
entering the EU. However, increased customs checks may be likely to lead to delays in journey
times for consignments, and possibly longer shipping lead times.

HM Revenue & Customs (HMRC) runs the Authorized Economic Operator (AEO) scheme.
While the scheme is not compulsory, companies that meet the requirements will be registered as
AEOs and can take advantage of simplified customs procedures that relate to the security and
safety of their goods in transit.

Export licensing and certification

An export license is required to export specified goods with military or a potential military use.
To determine if you need an export license, you need to check the UK Strategic Export Control
List which is a listing of controlled goods. The list of controlled goods includes materials,
chemicals, micro-organisms and toxins.

On 16 April 2011, controls were also introduced on the export of specified pharmaceutical goods
- potassium chloride, pancuronium bromide and sodium pentobarbital - to the USA. This follows
controls placed on the export of thiopental sodium to the USA which came into force on 30
November 2010 and continue to be controlled. The relevant legislative order is the Export
Control (Amendment) (No 3) Order 2011 (amending the Export Control Order 2008). These
controls are in place due to the risk that the goods might potentially be used in the process of
execution by lethal injection.
In addition to UK requirements, there are specific regulations that exporters in the healthcare and
medical sector need to comply with to protect their business. These relate to the wholesaler
dealers license, export licenses for controlled substances, and Certificates of Free Sale. One will
also need to find out the requirements of the country you are selling to, for instance, many
medical devices should be CE-marked. UK Trade & Investment or trade association may be able
to help.

64
Export licenses for controlled substances
Additional requirements apply to exports of controlled substances such as opiates and
nanotechnology. If one wants to export a controlled drug, one will need a domestic license before
applying for an export license.

For some substances, an import certificate from the country to which the substances are being
exported is required before the Home Office will issue an export certificate.
For medicines and pharmaceutical components, many countries require an export certificate
covering the product or its manufacturer. Export certificates are issued by the MHRA.

Tariffs and duties in the healthcare and medical sector

There is a range of import-specific regulations that must be complied with by all businesses in
this sector. The key issues relate to the Tariff, VAT and duties, Intrastate and IP.

Preferential rates of duty

The Generalized System of Preferences (GSP) allows products from a wide range of countries to
be imported in the EU at a reduced or zero rate of duty.
The EC has a number of other preferential trade agreements with third countries, in which goods
may attract preferential rates of duty. For instance, the EU duty on imports of certain medical
equipment is zero, as a result of the Uruguay Round of Multilateral Trade Negotiations agreed in
1994. Other countries where this deal is in force are the USA, Canada, Japan, Australia, New
Zealand and South Korea.

Import regulations in the healthcare and medical sector

As the EU is a customs union, one can generally buy goods from other member countries
without restrictions - although VAT and excise duty can still apply. One can also see the guide on
imports and purchases from abroad: paying and reclaiming VAT. For medicines, however, there
is a need of at least one license. Import from outside the EU, may have to comply with import
licensing requirements and with common customs tariffs that apply across the EU.

The European Commission has identified the need to secure supply chains for goods leaving and
entering the EU. However, increased customs checks may be likely to lead to delays in journey
times for consignments, and possibly longer shipping lead times.

HMRC runs the AEO for business. While the scheme is not compulsory, companies that meet the
requirements of the scheme will be registered as AEOs and can take advantage of simplified
customs procedures that relate to the security and safety of their goods in transit.

Import licences

65
Under Registration, Evaluation, and Authorization of Chemicals (REACH) legislation, importers
or manufacturers of more than one ton of chemicals a year must register with the European
Chemicals Agency and build an inventory of every chemical that comes into, is part of, or goes
out of the business. Traded products must be labeled and packaged according to specific rules.
Importers must establish if any substance (which is intended to be released under normal or
reasonably foreseeable conditions of use) is present in these articles in quantities totaling over
one ton.
Import restrictions can be product-specific or trade-specific. Many products are subject to
product-specific standards and need to be supported by applicable certificates, product-specific
licenses and documentation.

Restrictions or limitations on the quantity of some imports mean that one may have to pay anti-
dumping duties on the goods.
The trade in some goods may be prohibited unless there is a specific license issued by the
competent authority. These include wholesale dealers licenses and product licensing and
approval.

Product licensing and approvals

Imported medicines and medical devices can only be sold in the UK if they meet UK
requirements.
Medical devices that are imported from another EU country where they are approved for sale
automatically meet UK requirements. Medicines that are already licensed in other EU states still
need UK licensing, but can be licensed under the simpler parallel import licensing scheme.

Investing In the Healthcare Sector

66
The healthcare sector is made up of many different industries from pharmaceuticals and
devices to health insurers and hospitals and each has different dynamics. Investments in this
sector are affected by many variables, including positive trends related to demographics and
negative trends related to reimbursement.

Healthcare investing requires a multifaceted approach to understand the underlying drivers.

Investors can profit from investments in both the overall sector and/or its industries. This article
will detail the differences among the various healthcare industries and which metrics investors
should follow before making an investment.

Trends in the Healthcare Sector

When deciding on a healthcare company in which to invest, keep the following prevalent trends
in mind. Changes to or continuations of these trends can have implications for a variety of areas
within the healthcare sector.

Positive trends include:

the aging population and the baby boomers

people living longer with chronic disease
obesity and diabetes epidemics
technological advances
the global reach of disease
personalized medicine

Negative trends include:

a single-payer system (Medicare/U.S. government)

expenditure as an increasing share of gross domestic product (GDP)
the uninsured
cost controls
consumerism

Pharmaceutical and biotech companies both manufacture "drugs", but differ in how those drugs
are created. Pharmaceuticals are generally considered small chemical compounds that easily pass
through barriers or membranes in the body, while biotechs are considered large protein
compounds that have trouble passing through membranes.

These companies often spend a significant percentage of revenue on research and development
(R&D) to discover new compounds. The "hit ratio" is very low as discovery of new compounds

67
is very difficult and tedious. When investing in the drug companies, there are several things to
keep in mind. One needs to have some understanding of:

the underlying disease or condition that a specific drug treats

the number of people affected
the number of compounds currently available
the process of discovery and coming to market, specifically the rigorous clinical trials
required by the Food and Drug Administration (FDA)
the availability of substitutes, including generic versions of drugs
patents
the overall marketing framework, which may include revenue or profit-sharing
agreements with other companies

This is an industry that is greatly affected by clinical-trial data, and surprises about the outcomes
of the data can affect the stock price tremendously. Positive surprises - better-than-expected
clinical data, faster time to market, etc. - can cause stocks to appreciate significantly in a short
time period, while negative surprises can have the opposite effect. In addition, aftermarket data,
such as the number of prescriptions written, market share, FDA warnings or the loss of a patent
will affect investments. This is an industry that requires active monitoring on the part of the
investor.

Facilities

The providers of medical services - the hospitals and clinics - are the cornerstone of healthcare in
the U.S.U.S. laws mandate that all facilities with an emergency room treat anyone that walks
through the doors, regardless of whether that person has health insurance or money to pay for the
services. This legislation has created strong competition to hospitals in the form of free-standing
clinics and specialty hospitals, which do not have emergency rooms and, as such, are not
required to provide services to everyone.

These clinics are able to pick and choose which patients to treat and benefit from higher
payments from insurance companies. Meanwhile, hospitals are faced with bad debts impacting
their profitability. The bad-debt ratio is an area of focus for investors. In addition, cost controls
are key for hospitals' profitability. Many hospital systems have yet to make technological
advances like electronic medical records, proper purchasing and operating systems a part of their
standard operations, although this seems to be changing.

Medical technology and device companies manufacture a host of medical products, from
bandages all the way to artificial joints and heart stents. These companies, similar to the drug
manufacturers, spend a large percentage of revenues on R&D, and some need to follow the same
clinical-trial path. Investing in these companies requires knowledge and analysis of the new
technology as well as the competitors and known substitutes. Adoption rates and gross margins
are important indicators of a company's success, which is similar to other technology companies.

68
Investing in healthcare stocks can provide generous returns, but it is also tedious due to the many
factors affecting stock prices. The healthcare sector is vast, and there are many large and small
companies to choose from in various industries. To help ease the burden, there are investment
vehicles like ETFs and healthcare mutual funds in which you can invest; they can reduce the
volatility of investing in individual stocks by diversifying holdings.

Recent News

RBI formalizes automatic 100% FDI in medical devices sector

Medical device manufacturers in India will be able to bring in foreign direct investment (FDI) up
to 100% through the automatic route, the Reserve Bank of India (RBI) said on Monday,
formalizing a government decision taken in this regard in January.

Until now, the medical devices industry has been considered part of the overall pharmaceutical
sector, where 100% FDI is allowed through the automatic route in new projects; however,
existing companies can do so only with permission from the Foreign Investment Promotion
Board (FIPB), in what is called the approval route. The RBI clarification essentially carves out
the devices industry from the pharmaceutical sector for regulatory purposes and opens it for
100% FDI through the automatic route.

In 2014, the government had reviewed the FDI policy for the pharmacy industry to restrict the
100% automatic approval route only for Greenfield or new units and insisting on FIPB approval
for existing units. This review was prompted by concerns that 100% foreign investment though
automatic route in existing units would lead to increased inbound mergers and acquisitions in the
sector, driving pharmaceutical manufacturing to the control of foreign companies.

On 6 January, the government said it will allow 100% FDI for medical devices manufacturing in
India. All kinds of medical instruments, diagnostic tools and products, any technology and
products including clinical implants were included in the category. It was also proposed that the
FDI approval restrictions on the pharmaceutical industry will be removed for medical devices.
Mondays RBI clarification mandates this policy recommendation.

Allowing 100% FDI in the medical devices sector is aimed at promoting local manufacturing of
these products, as currently India meets at least 70% of its requirements through imports.

The local industry, however, says automatic approvals may not necessarily result in boosting
local manufacturing as many foreign companies may use this rule for setting up their local
subsidiaries in the country to import and trade in products.

The government decision to allow 100% foreign direct investment in the area of medical
devices is welcome, but the government should also have the required mechanism to scrutinize
the use of such investments to ensure that it actually results in reducing the imports, said G.S.K.

69
Velu, founder and managing director of Trivitron Healthcare, one of Indias top medical devices
companies.

In December, local medical devices manufacturers had cautioned against allowing 100% FDI
through the automatic route, saying large foreign companies may misuse this provision to set up
local subsidiaries and continue imports.

The RBI clarification essentially carves out the devices industry from the
pharmaceutical sector for regulatory purposes and opens it for 100% FDI
through the automatic route. Photo: AFP
Fig 10
The Association of Indian Medical Device Industry welcomed the proposal, while urging the
government to ensure that the FDI is used for local manufacturing, not trading. Citing a previous
experiment (since withdrawn) when the government invited US companies to set up such units
under 100% FDI, the association said these companies set up fully-owned subsidiaries to import
stock and market their products, instead of manufacturing.

Conclusion:-

70
With the research conducted on this report it can be concluded that global market place is very
competitive, and the shrinking of the world through technology has made it easier for companies
to reach global markets. Companies cannot just concentrate on domestic markets if they are to
remain competitive. Global marketing allows marketing managers to look for growing target
markets and product opportunities overseas. Global marketing of products improves the living
standards of international countries.
A wide variety of digital innovations are revolutionizing healthcare and technology in
medicine is here to stay. Though technology has been permeating almost every aspect of our
lives, until recent years the medical field has been largely unaffected by the rapid pace of
technological innovation that is characteristic of the Digital Age. However, this is changing. This
ubiquity of technology is beginning to extend into the medical field. Advances in medical
technology are changing medicine by giving physicians more information as well as better,
more specific data.
Over the years, India has grown to become a top-notch destination for medical value travel
because it scores high over a range of factors that determines the overall quality of care. India
was one among a few countries to recognize the potential of medical tourism for which it is the
leading destination for global medical tourists today. Medical tourism in India is expected to
grow at the rate of 30 % in 2015 and India`s decision to offer medical-M-visa on- arrival to
citizens of 180 countries will be a big boom for the medical tourism Industry In India. The
government in the country is supporting this industry by assisting hospitals in acquiring the Joint
Commission International accreditations and awarding funds for renovations and additions.
Regulations, charges or other restrictions may apply to healthcare and medical exports as they
leave the UK and when they arrive at their destination country. Use of standardized classification
codes makes it easier to check if any restrictions or charges apply. An export license is required
to export specified goods with military or a potential military use. Import restrictions can be
product-specific or trade-specific. Restrictions or limitations on the quantity of some imports
mean that one may have to pay anti-dumping duties on the goods.
The trade in some goods may be prohibited unless there is a specific license issued by the
competent authority. These include wholesale dealers licenses and product licensing and
approval.

References

71
 HRSA Focuses Agency Resources on Telehealth. Rockville, MD, Health Resources and
Services Administration, HRSA Press Office, May 22, 1998.

http://konsultapp.com/international-services/

http://online.king.edu/healthcare/digitizing-healthcare-how-technology-is-improving-
medical-care/

http://www.embassyofindia.kg/pages.php?id=279

http://www.healthcaresuccess.com/doctors/essential-doctor-referral-marketing-strategies

http://www.investopedia.com/articles/stocks/08/investing-in-healthcare.asp

http://www.marketingdonut.co.uk/marketing/marketing-strategy/exporting/ten-ways-to-
improve-your-international-marketing-strategy

Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunications in Health

Care, Committee on Evaluating Clinical Applications of Telemedicine. Field MJ, Editor.
Washington DC: National Academy Press, 1996.

Kumekawa J. Telehealth and the Internet. Office for the Advancement of Telehealth,
Health Resources and Services Administration, July
2000. http://telehealth.hrsa.gov/pubs/inter.htm.

Protecting Consumers Online: A Federal Trade Federal Commission Report on the First
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