Health In The Hills - Dr. Modi's Health Resort

The week I spent at Dr Modi’s was one of the best in my mis-spent last decade. It was so satvik, like Yudhishthira I was walking two inches off the ground when I left.

But the satvik-ness apart, there is much else to keep one’s feet off the ground at Dr Modi’s. The resort covers some 55 acres (22 hectares) of which 27 are developed, and is pleasantly tree-laden and landscaped. Karjat in the last couple of years has received 250 inches of rain between late June and late September and there is commensurate greenery in the area. The low hills of the Western Ghats stand around, and altogether it is very pleasant.

The feel and facilities of Dr Modi’s Health Resort are at par with a 4-star hotel. The service is good and the people who work there well trained, despite not being from catering or hotel institutes. This owes perhaps less to Dr Modi — who focuses on his patients — and more to his charming wife Usha, who has managed his affairs for 30 years.

There is precious little to do at the resort except to commune with yourself and concentrate on your health, and that is as it should be. I only switched on the TV once, soon after I arrived, to see what channels were available. Otherwise there is the walking track, a nicely designed oval of 320m surrounded by green; there is a 25m-long swimming pool with a walking jacuzzi; there is table tennis; and there is a fine long road to walk up and down. The road is lined with the cottages for guests. At its end is the Health Club with Dr Modi’s consulting room and the rooms for all the treatments.

It is worth taking the Health package for a week, just to detoxify the system. We Indians eat a lot of oily food, but the feeling of well-being produced by the diet here will make you want to change your lifestyle. Diet, in fact, is a very important component of overall health to the Modis. They are almost finicky about it. Mrs Modi asks, “What can be eaten raw or sautéed, why cook it?” Dr Modi sets out the body’s timetable: “Absorption is from 8 pm-6 am; only water should be taken then. The time for elimination is 6 am-12 noon; during that period, eat only fruit, raw vegetables and sprouts. Assimilation takes place between noon and 8 pm, lunch and dinner come in that time. But no milk products at all, or fried things, or sugar.”

Dr Modi recommended that I eat only fruit for three days. I could have done it, but knew I would be unhappy, so we compromised on one day. Since breakfast on the Health package is always only fruit, that meant I went 40 hours without eating anything else. But it put the roses in my cheeks. I also lost 2 kg in five days.

The special treatments are also well worth it. Of course they are old hat to many city dwellers now, when apartment buildings have gymnasia and saunas and jacuzzis. It is different, however, when someone is taking care of you. (I even enjoy a visit to the dentist, simply because it’s so rare in our crowded lives that a comparative stranger evinces such concern for your health.) So to be oiled and pummelled and massaged into shape by the masseurs at the resort gave me a feeling of supreme contentment.

As it happened, I was suffering from some back pain when I visited the resort, and had a perfectly legitimate reason for consulting Dr Modi. I’ve also had a bad knee of old. Dr Modi made an examination, just as any physician would, and recorded my case history. Then he asked me to lie on a high couch and set to work.

Osteopathy is all about manipulation, not massage, and some of Dr Modi’s holds resembled scenes from the akhara. He seized my leg, thrust his arm behind the knee and threw his weight on it; he worked the joints around; he pressed my spine into place. Though short statured he is quite powerful, and long years of this work have trained him to use his weight. Some of the manipulations approached the threshold of pain but, after half an hour of therapy, when I stood up I felt curiously lighter. (See ‘Osteopaths and their manipulative ways’ on facing page).

Some of the patients I saw visiting Dr Modi were unable to even lie down with ease, and many were unable to walk. Clearly his osteopathic self is consulted by serious ‘patients’. There is usually a two-week gap given between osteopathy treatments.

The Health Club has a women’s and a men’s section with separate attendants, all trained personally by Dr Modi. Tell them of any specific aches you suffer from and take some old clothes along, especially underwear, since massage oil has a way of sticking to you.

The oil massage, lasting most of an hour, is done in the North Indian Naturopathic style (not the Kerala Ayurvedic, now so popular) with copious amounts of oil. The mud bath is not really a bath: it involves sitting in a chair on a sunny terrace while clay is liberally plastered all over you. You stay there till it dries — good for the skin. The full body wrap means you are wrapped in soaking wet sheets and stay immobile — the only treatment I found actively uncomfortable. The jacuzzi here is a sit-down bath for two, while powerful jets of water assail your body. (There is a 'walking jacuzzi' at the swimming pool.) The steam bath is a box in which you sit with only your head outside and have the sicknesses sweated out of you. Very enjoyable, as is the sauna, a small room with fresh-smelling wooden benches on which you sit while you are literally steamed. The temperature goes up to 80o C here.
The health package is flexible. Dr Modi prescribes, but if you feel any particular treatment — such as those for weight loss — is doing you good, you can probably ask for a repeat.

Strangely, there were relatively few guests at the resort on the Health package. Dr Modi’s regular patients for his osteopathic treatment come every weekend, mostly from Mumbai but sometimes from farther afield. But there is always at least one conference going on. These could be workshops, or marketing conventions, or simply company pleasure trips. Everybody lets their hair down and relaxes. But Dr Modi’s Health package definitely deserves a try: staying for a week or so on this package is itself a rare chance to rid oneself of stress and to detoxify the system in idyllic surroundings.

ABOUT DR MODI’S
Dr Modi’s Health Resort was opened in April 1998, but Dr Modi himself continued to practise in Mumbai and visit the resort weekly. In 2003, however, he and his wife shifted here for good. They manage the place themselves. Since the resort as it exists is only four years old, it cannot be said to have taken final shape. The Modis have plans to develop it and offer more therapies, including Yoga.

The chief attraction of the resort is undoubtedly not the resort itself: It is Dr Modi’s reputation as India’s first osteopath, and his record of treating some 50,000 patients over 35 years without using invasive techniques.

The ailments he has successfully combated include slipped disc, sciatica, cervical spondylosis, tennis elbow, migraine, arthritis, knee pain and dysmenorrhoea. He is also consulted about high blood pressure, weight loss programmes, diabetes, chronic stomach problems, and de-stressing and rejuvenation programmes. Some 30 patients, mostly from Mumbai, visit him from Friday to Sunday, and another half-dozen during the week. His dream is to found a college of osteopathy, which would be India’s first.

TREATMENTS AND TARIFFS
Osteopathy, Rs 2,000 per session with Dr Modi personally.
Health Club treatments (included in the Health package): Full body massage Rs 400; Mud bath Rs 400; Full body wrap Rs 250; Aroma facial Rs 350; Jacuzzi Rs 250; Sauna bath Rs 250; Steam bath Rs 250; Head massage Rs 200. The main massages are for 45 mins, facial for 30 mins, and the baths for 15 mins.

THE THERAPISTS
Dr Krishna Murari Modi claims to be the first osteopath to practise in India, and he is certainly one of the very few. His father, Dr Vithal Das Modi, was interested in Naturopathy and travelled all over India collecting and studying therapies. In 1947 he set up Arogya Mandir, now a 100-bedded Naturopathy hospital, in Gorakhpur, Uttar Pradesh, and also founded a health magazine, Arogya, which is still being published.

Dr Modi took his MBBS from GSVM Medical College, Kanpur, in 1964. Until 1966 he was at the Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi. Dissatisfied with what he considered an incomplete science, in 1966 he went to the UK and joined the London College of Osteopathy, of which he is a Member. From 1969, he worked at Arogya Mandir for seven years.

In 1976, he and his wife moved to Mumbai where he quickly attracted a large and varied clientele. He practised in Mumbai from 1976 to 2003, and had a number of illustrious patients, including painter MF Hussain and illustrator Mario Miranda who helped him with his book on health farms.

Dr Modi takes a keen interest in sports. A story he proudly recounts is about how he cured Test cricketer Dilip Vengsarkar, now Chairman of Selectors, of a back ailment, and helped his career to flourish without surgery.
Dr Modi has published two books: Health Farming (Health Farm Publications, 1989; now out of print but to be re-issued) and Cure Aches and Pains through Osteopathy (Orient Paperbacks, 1997; Rs 95).

The masseurs and other attendants at the resort have been personally trained by Dr Modi.

Cost-effective Medical Treatment: Putting an Updated Dollar Value on Human Life

By Andrew Simonds & M H Ahssan

A thorny question lies at the heart of meaningful health care reform. How much is human life worth?

New research from Wharton and Stanford based on Medicare kidney dialysis data shows that the average figure -- $129,090 per additional year of quality life -- is higher than prior studies have shown. Perhaps more important, the study also puts a value on the cost-effectiveness of treatment across percentiles of the entire dialysis population in an attempt to develop a benchmark for health care coverage decisions.

As presidential candidates again debate universal coverage, the research could provide guidance to policy makers attempting to allocate scarce health care resources in the most effective way possible, according to Chris P. Lee, a Wharton professor of operations and information management, who co-authored the paper titled, "An Empiric Estimate of the Value of Life: Updating the Renal Dialysis Cost-Effectiveness Standard." The paper is to appear in an upcoming issue of the journal Value in Health.

"Health care costs are rising rapidly and it's believed that much of the rise in medical expenditures is attributed to the use of medical technologies that are too expensive to be justified," says Lee. "What we're asking is: 'Does the medical benefit support the kind of costs we're talking about?'"

Dialysis for patients suffering chronic renal failure is the one service that Medicare, the national health plan for the elderly, provides for anyone, regardless of age. The program has been in effect since the 1970s and health care economists have long considered it to be a fair proxy for universal health care coverage and the value that society places on a year of life.

Lee and his co-authors, Glenn M. Chertow, of the division of nephrology at Stanford University's department of medicine, and Stefanos A. Zenios, of Stanford's Graduate School of Business, examined records from more than a million patients. The study results show that the incremental cost effectiveness ratio of dialysis in current practice relative to the next least costly alternative is on average $61,294 per year, or $129,090 for a quality-adjusted year of life (QALY) -- a measure that combines the length of time that life is extended and the quality of that life.

However, the distribution of cost effectiveness across the entire population is wide. For the lowest percentile, it costs only $65,496 to provide an additional quality-adjusted life year. For the top percentile, the figure is $488,360. The higher costs per quality adjusted life year were strongly associated with old age and additional chronic illnesses in addition to end-stage renal disease, the researchers found.

"I don't believe that any health economist or the strongest advocate for providing coverage will argue that half a million dollars for one year of life is reasonable," says Lee. "This would inflate health care spending by a large amount -- 10 to 15 times what we currently spend. Obviously that's not feasible."

Lee points out that the cost to preserve one year of quality-adjusted life drops to $240,000 in the 90th percentile of expenditures. In effect, if that were to become the threshold, 90% of patients could be treated for half what it would cost to treat the sickest for whom heavy expenditures do not improve the quality or length of life very much. Coverage decisions are shaped largely by the medical community, Lee says, adding that while this community includes caring and informed professionals, they are not often focused on quantitative analysis and miss some of the subtleties that emerge in the data.

Up until now, according to the paper, the most commonly used number to place a value on a year of quality life has been $50,000. It, too, is based on a study of dialysis patients. The 1984 Canadian study used an accounting ledger for 44 patients at one center during a time span of one year. A more recent study adjusted that number to $93,500 per year, inflating the earlier number to 2002 U.S. dollars.

The new Wharton/Stanford research brings older renal care studies up to date with costs and modern practices, says Lee. "The gold standard has been $50,000, but that figure does not reflect the way dialysis is practiced and the technology we have today."

Lee and his researchers used data from The United States Renal Data System (USRDS) for information on outcomes and costs from more than 500,000 patients initiating dialysis between 1996 and 2003, as well as from 159,616 patientswho received a transplant during the same period.

The paper also puts the value of extended life implied by medical spending on dialysis in the context of other ways in which the value of life is calculated, outside the medical field.

For example, the paper points out that the decision to work as a contractor in Iraq involved placing a monetary value on years of extended life. Assuming an annual risk of death of 0.004 and a salary premium of $30,000 per year over comparable jobs in the United States, contractors in Iraq are essentially compensated at a rate of $250,000 per statistical year of life. The study also points to a recent survey of estimates based on occupational risk that found a range from $500,000 to $21 million per statistical life year depending on how dangerous the work is.

Another approach is based on the cost effectiveness of life saving interventions in non-medical fields such as occupational health, transportation safety or environmental hazard control, the paper states. Estimates using these methods ranged from a cost-effective $56,000 per life year saved for transportation programs to a more extravagant $4.2 million per life year saved for environmental programs.

As the paper states: "While no method can definitively determine the actual value an individual places on his or her lifetime, these estimates are less prone to some of the problems faced by estimates using labor market data or personal choices involving small but finite risks, which ... people tend to overestimate."

Implicit and Explicit Rationing
When it comes to medical care, placing a value on life leads to ethical concerns, the paper acknowledges. Lee notes that when officials in Oregon attempted to introduce cost-effectiveness to state Medicaid programs, the proposal was shot down in an angry public outcry.

"In this country we're really uncomfortable with the notion of health care rationing," says Lee. "On the other hand, the fact of the matter is when you have finite resources -- and that is the case here -- you are always rationing, whether explicitly or implicitly. Using rankings of the cost-effectiveness of medical interventions to make coverage decisions is explicit. Without that, we are rationing implicitly because Medicare has a finite budget. It can't provide coverage for everything. In the end, people will not get everything they want. It's just that the mechanism for the rationing is a lot fuzzier." Medicare coverage, he says, is based on a clause that states patients must receive treatments that are "necessary and reasonable."

"This magical phrase has been the benchmark by which coverage decisions are made in this country," says Lee, adding that without incorporating the benefit derived from the procedure, it is impossible to know what is medically necessary or reasonable. "This whole phrase is really subject to interpretation and, because of the subjectivity, we don't even know if our decisions are based on objective notions of medical benefit."

Lee notes that the $129,090 figure his research came up with compares to a range of $50,000 to $100,000 used in other countries, such as Australia and the UK, which run national health care systems in guiding their coverage decisions. The World Health Organization has proposed $108,609 as the value of a disability-adjusted life year, Lee says, adding that even though other countries have adopted the use of "pseudo-official" spending thresholds in coverage decisions, they do not apply them rigidly and without exceptions. And while other nations are more oriented toward universal health care, the United States has favored a market-based system. "But it has not been as successful as we might have liked. Perhaps it is time to revisit the pros and cons of this approach," says Lee.

Indeed, debate on the cost of the new Medicare prescription drug benefit program (part D) suggests that continuing on the path where coverage decisions are based on clinical evidence alone, without consideration of costs, may not be feasible in the long run, according to the paper. The drug benefit has led several researchers to argue that coverage decisions should be based on cost and effectiveness criteria. New technologies with cost effectiveness ratios below $50,000 to $100,000 per incremental quality-adjusted life year are deemed suitable for coverage, while others with higher ratios are too expensive, the study states.

Too Little Benefit for the Cost
The paper argues that creating thresholds for treatment needs to keep with principles of social justice established by the American political philosopher John Rawls. Rawls argued that there are many different ways to define justice, including protection of the most vulnerable in society, according to Lee, who adds that because medical cost-effectiveness varies so widely, the system is never going to be able to afford to treat everyone at the most expensive level. Attempting to provide the maximum amount of medical care in a system that cannot finance that spending will inevitably leave people out.

"The Rawlsian notion of justice is noble in its attempt to protect society's most vulnerable, but implementing it in practice is difficult," says Lee. "If we're to set coverage at the sickest and most cost-ineffective patient there is, it means we will be expending a lot of resources for what may be a barely detectable increase in life expectancy -- an amount that is sometimes measured in hours if not minutes, especially in end-of-life situations. When resources are scarce and costs are rising fast, this would not be sustainable and it means that somewhere someone else who can benefit more from the same resources will get excluded from coverage because we have exceeded our ability to pay.

"What we realized in the course of this study is that a more pragmatic and modern interpretation of Rawls' argument is to think about coverage in terms of the percentile of patients up to whom we will cover rather than focusing on the coverage of the last and most expensive (cost-ineffective) patient whom we can't afford to cover," says Lee.

The research concerns the business community in several ways, including employer and employee health benefit payments, insurance coverage and malpractice cases, according to Lee. "Health care costs are rising for employees, but employers are also paying more," he says. "Health insurance is expensive partly because of the degree of coverage. The fact of the matter is that there are a lot of medical procedures with high prices and minimal medical benefit." When is it justified for one person to subsidize the demands and wishes of someone else? asks Lee. "So the question is, 'How does a health plan or employer determine what is the right degree of coverage to provide, and at what point do we say this coverage produces far too little benefit for the costs demanded?"

For that, the paper "provides a practical benchmark based on renal dialysis," Lee says. "To the extent that we, as a society, believe that renal dialysis -- given its unique historical status -- offers a reasonable point of reference for making coverage decisions, the findings in this paper can be used to guide those decisions. And despite the fact that the $129,090 figure is substantially higher than the often-quoted, but now outdated, figure of $50,000, using the former as the benchmark doesn't necessarily mean we will be spending more money than we already are. What it means is we will allocate resources using renal dialysis as the reference point that defines what is cost-effective and what isn't. It provides a more rational approach to allocating scarce resources."

Lee suggests new quantitative research on cost-effectiveness could also be used in malpractice litigation which, he says, also has an impact on the health care costs. For example, in a case where negligence cost a patient 10 years of quality-adjusted life years, lawyers could at least use a figure of $1.29 million as a rough start for settlement negotiations. Lee was recently contacted by an attorney for a doctor who was being sued by a patient seeking more than $20 million in damages.

"The importance of providing a benchmark is that it establishes a precedent for how this compensation should be set," says Lee. "Malpractice lawsuits in this country are rampant, and a lot of times there is no consistency in how a court awards the plaintiff."

He argues that increasing numbers of suits have ended in higher payouts that have set new precedents. "The costs of malpractice lawsuits, which are going up and up, have hurt the health care system in the sense that physicians and hospitals pay those fees and, ultimately, the people foot the bill." He also points out that in order to avoid being slapped with a malpractice suit, doctors and hospitals now practice defensive medicine, ordering excessive tests and treatments which, in turn, are driving up the overall cost of health care.

"As the spending on health care continues to rise unabated -- right now it is growing at twice the rate of inflation and accounting for one out of every six dollars we earn -- we as a society will soon come to a point where compromises are inevitable: Either we cut back other forms of spending to make room, or we spend our health care dollars more wisely. There is just no other way," says Lee. "This paper provides guidance and the tools for making those decisions. These decisions are hard because they involve ethics and social values where there is no right or wrong. But if we can just get people to think a little more about medical value and the difficulties involved, we think we have done a good job."

Opinion: My Health Records? Directly Post On FB, Cloud

While the West may be paranoid about privacy of personal health data, in India, it appears, people hardly have privacy as their primary concern. Call it a cultural thing or an evolutionary response to the pitiable public health we have. People are not only willing to share their health records over social media but are more than happy to submit their genetic information to a doctor or healthcare professionals to ensure they have all the information available to treat.

In a 10-country survey of consumers’ attitudes toward technology in healthcare that Cisco released this week, Indians turned out to be the most advanced. Of those surveyed, 62 percent of Indians showed a willingness to share a range of information regarding their health as compared to a 42 percent global response rate. When it comes to trust in devices, 87 percent of Indians were up for it, as compared to 70 percent globally.

The data gets more impressive when you look for consumer trust in the ‘cloud’: 94 percent in India said they were comfortable having their health records in the cloud (hosted by healthcare or other service providers), assuming adequate security, whereas only 74 percent respondents in other countries expressed confidence. Mobile health is no different: 60 percent acceptance in India versus 40 percent elsewhere.

Even health care decision makers in India are ahead of their counterparts in other regions, though in many cases they are behind the consumers in India. For instance, while 60 percent of the consumers surveyed said they have no issues sharing personal data if that improves the quality of future care, only 45 percent of healthcare decision-makers believe that such data should be shared.

The survey includes responses from 1,547 consumers and 403 healthcare decision-makers in four age groups from 18 to 67 years. So that means about 200 people from each country were surveyed. Not a sample size that can be called truly representative of India (or any country for that matter), especially if we account for the vast population in rural areas that have hardly any access to technology.

Vishal Gupta, Vice-President and General Manager, Global Health Solutions, at Cisco argues that these studies give “directional shifts”. Additionally, in India, Cisco has collected data from 29,000 consultations in Karnataka and Madhya Pradesh across seven district hospitals and 20 primary health centres in the last 18 months. That data, he says, shows people are accepting virtual diagnoses and consultations with much ease.

Why is Cisco doing surveys on healthcare attitudes?

Cisco has quite a lot riding on the acceptance of virtual healthcare and customer service. It has been developing technologies and solutions, both high-end and low-end, for health care. But most of them remain in pilot stages. So the networking giant did this survey to show that virtual healthcare is no longer a myth. While the survey has brought out some interesting findings, they are hardly surprising. In a country which has glaring shortages in healthcare professionals – according to WHO India should have 23 health workers per 10,000 population but what we have is merely 12.9 – technology is the only means of bridging this gap.

But here’s the challenge: initial support or incentive for adoption of such technologies – be it electronic medical records or e-prescription or virtual diagnosis – often comes either from the government or the payers. The governments either fund it or lay standards, say, for electronic medical records (EMRs), to make them mandatory. All such initiatives here seem far in the realm of just planning; rather in the 12th Plan document. If the Universal Health Coverage that the Prime Minister talked about early last year had moved towards reality, which it hasn’t, as this earlier story in Forbes India shows, EMRs would be the starting point.

As technology providers like Cisco see it, basic healthcare could be delivered via kiosks-like ATMs. Practically speaking, it is doable. After all, the banking and financial services sector in this country has seen tremendous growth because of such innovation. But the catch is there is no single body like, say, the RBI, Sebi, or Irda, which transformed financial services, in healthcare to bring sweeping changes.

Rajendra Pratap Gupta, Chairman of the India chapter of non-profit Healthcare Information and Management Systems Society (Asia Pacific), believes insurance companies will drive IT deployment in India. In three years, he says, India will see patient groups demanding such technologies, just as they influence policy and other decisions in the developed countries.

My hope too is the patient demand. Unless consumers start demanding it and differentiating care providers on this basis, change will be very slow to come.

'They Still Die in Labor Room'

By Samiya Anwar & M H Ahssan

Taj Mahal- One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of the Queen Mumtaz , by her husband Emperor Sahajahan, is a testimony and a grim reminder of the tragedy of maternal mortality, that can befall any women in childbirth. The probability of an Indian mother dying during childbirth is roughly 10 times that of her Chinese counterpart. Reducing the Maternal Mortality Ratio (MMR) by three-quarters in 10 years is now a Millennium Development Goal. Why is MMR in India so high and how far are we from the goal? HNN unravels the many challenges to saving mothers' lives.

Maternal Death - A Tragic Reality
Women, undoubtedly is the most beautiful piece of creation. She is not just a female, she is more than it. She is definitely a special handiwork of God. That is why she is wanted, she is loved. Men love women. Isn’t so and why not they are always surrounded by women. First it is a woman, to whom they are born. Then they grow with women as sisters. They are married to women. And also women are the one who reproduces the generations. Yes, because women are the reason for the offspring and growth of society.

But the same women are put to menace for procreation of mankind. They are often treated as reproducing machines. Not cared, left as scraps or doormats at homes women die anonymously especially the poor. For women it is a joyful start to a life as the mother and for a child a whole new life. It is really indecent that there is no man or women who take care of them or good medical facilities when the women are in need of special care and attention during and after pregnancy. Hence they either develop complications in the womb or die soon after child birth. Lack of education and short of medical facilities would be the cause. Many stories of women dying with maternal deaths are largely untold and unheard.

This is a social issue and heeds attention. Thanks to the television channels for wonderfully presenting the shows on social problems. Balika Vadhu, is such a social serial on Colors, which had so far portrayed the maternal deaths of young women. It is a mirror of Indian Society. The Indian Government estimates that 301 women die annually for every 100,000 live births. In some states the maternal mortality ratio is even higher -- 358 in Orissa, 371 in Bihar, and 379 in Madhya Pradesh. It is also estimated that few rural women chooses to remain passive. Laajwanti (name changed) a rural girl barely 16 has no complaints; however, she says “It’s a woman’s duty to produce as many children she can. They are God’s gift.” It is been observed that the maternal mortality rate has risen faster as there is pressure on girls to produce as soon they reach puberty. It is a shame to our country which is developing but not the people. We’re still backward. Right!

As the new data analysis tool reveals an estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia. Since many deaths happen in the anonymity of women's homes or on the way to seek help at a medical facility, they often go unrecorded. It is absurd because we know about such practices, we have heard it, we have also listen to the news channels and read in several newspapers but still there is no official complaint.

Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. After achieving so many laurels in academics, still we’re not fully educated. Though the enrolment in schools has risen from past, our country yet suffers from problems due to lack of information and knowledge. Also in Purulia, West Bengal, 48% of the women who had died had no formal schooling. That’s a real embarrassment. In Bihar’s Vaishali, we can see 42% of the deaths occurred due to Haemorrhage, the most common cause of delivery-related deaths, with almost all hemorrhages occurring after delivery. Many women who delivered at home also died from postpartum hemorrhage. Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places. These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.

Causes may be:
- Early marriage,Hidden pregnancy, history of abortion, etc
- Financial disasters, No medical facilities
- Smoking, drinking and drugs (urban women)
- Lack of knowledge (like the example I gave about Laajwanti above)

Maternal death is a sensitive issue of human race. We need to curb the social ailments from the society. It is like terrorism killing the number of innocent lives in the dark of ignorance. Though it is hard to eliminate fully from the society we can generate proper awareness about the loss of humanity with every mother dying during and post pregnancy.

Maternal mortality: This India story is a shame!
Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. In Purulia, West Bengal , 48% of the women who had died had no formal schooling.

Haemorrhage is the most common cause of delivery-related deaths, with almost all haemorrhages occurring after delivery. In Bihar’s Vaishali, 42% of the deaths occurred due to this. Many women who delivered at home also died from postpartum haemorrhage.

Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places.

These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.

A new tool, Maternal and Perinatal Death Inquiry and Response (MAPEDIR), has been developed to analyse the underlying medical and social reasons behind maternal death and is being used across 16 districts in Rajasthan, Madhya Pradesh, West Bengal, Jharkhand, Orissa and Bihar providing an ongoing, systematic collection of data to reconstruct and analyse the cases of 1,600 women—the highest number of audited maternal deaths in the world. MAPEDIR also informs health officials about the challenges local women face in accessing reproductive health care.

“The tragic reality is that too often maternal deaths are not visible. They don’t leave any trace behind, and their deaths are not accounted for. Unicef is committed to continue working with the National Rural Health Mission to promote surveillance as a key strategy to lower maternal and child mortality,” Chris Hirabayashi, Unicef India deputy director of programmes, said at a meeting with health officials from the six states who are using MAPEDIR.

“Unless we know the main reasons for maternal deaths we cannot take effective measures to tackle them. The traditional system did not deal with the issues adequately. Now using MAPEDIR, we can know if the death are due to delays in decision making at household level or lack of transport or delay at the facility or a cumulative of all three,” S P Yadav, director of medical and health services in Rajasthan said.

A team made up of state government health and nutriti on officials and NGO members, headed by a member of the local village council or Panchayati Raj Institution, conducts interviews with surviving family members at community-level with technical support from Unicef and funds from the United Kingdom’s department of international development (DFID) work under MAPEDIR.

Social and economic factors like the low status of women in communities, the poor understanding of families on when to seek care, lack of transport, poor roads, the cost of seeking care, multiple referrals to different health facilities and a delay in life-saving measures in rural areas have been listed out by Unicef as the reasons behind the high MMR.

Many of these deaths happen in the anonymity of women’s homes or on the way to a medical facility and so they often go unrecorded. An estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia.

Who cries when mothers die?
Munna was nine months pregnant. She did experience pains few days back, when her husband and mother-in-law rushed her to the nearest primary health centre in Kushwai of the District Shahdol in the State of Madhya Pradesh in India. They had to make her travel by bus from their village, and then in pain Munna had to walk, which she could barely to reach the health centre.

But unfortunately the kushwai health centre, where they had come with lot of hopes, did not had a medical doctor for last one and half years. One male health worker mans the centre. Though, he puts in his best but that may not be enough for women like Munna and others who need medical support.

Inspite of reaching the primary health centre, she did not get any help. She has to travel another eight kilometers to Burhar, the place where there is a community health centre. The centre is fortunately newly built and has facilities for delivery. Munna did develop some complications during the delivery but fortunately survived to see her new born.

She was lucky but thousands of women which die in the state are not. App 10,000 women die every year in Madhya Pradesh during pregnancy or within 42 days after pregnancy. Majority of these could be prevented. Medically these deaths may be due to hemorrhage, infection, eclampsia or unsafe abortion or any of three delays. But fact is there exists a yawning gap in our health system which stands in between life and death of women in the state. This gap has linkage to availability and access to health services, infrastructure, awareness among communities of not only the services but even recognizing danger signs, issue of how where they can access the services etc. Studies also tells us that for every maternal death in India, 20 more women suffer from the impaired health.

But if the situation at ground is like this, and has been there. What is the state’s response to an issue like this? Does it impact the political leaders, their discourse? Does issue of women dying in the state is debated in discussions where funds are allocated or decisions are made? Does state’s machinery care for it? Does civil society raise its concern?

To answer some of these questions a dip stick assessment was done in year 2004 at various levels within civil society, debates in the state assembly, media analysis. Outcomes were revealing. First of all the issue concerned only few in health department. There were only handful of civil society partners, and their major role was to support service delivery system. As such there was no push or urgency to bring change. Interestingly, the issue had never being debated on the floor of the state assembly, a place where elected representatives ‘of the people, for the people and by the people’ decide. It did not impact them, many of them were not even aware of the fact that state has this high number of maternal deaths? An issue like this was never raised by the political leaders in the debates which happen there – an issue of total neglect at the highest political body. Media covered ‘event news’ around the safe motherhood day, probably they never got the right information too.

That was a starting point, but nevertheless situation has changed today. Today state recognizes it as a major issue when it comes to women and children. State calls for an action. It is on high priority list of the political head of the state, state party is being questioned on the number of deaths, gaps on the infrastructure and many related points. Today more than 150 civil society organizations are raising concern on the issue and demanding urgency and urgency of action in the state.

How it happened and what does it impact and what strengths does it generate? Movements don't just happen; the energy that underlies them must be marshaled, channeled, and focused. The principal means by which this is achieved in our society, and within our political tradition, is through advocacy networks and coalitions.

Networks like Madhya Pradesh Voluntary Health Association, Madhya Pradesh Jan Adhikar Manch and Collective for advocacy, resource and training, Madhya Pradesh Samaj Sewa Sanstha, Mahila Chetna Manch, and many others have not only contributed to help bring the issue at an individual level but as a part of informal collation added to that force which helped bringing the agenda on political normative framework. Some of the strengths which this informal network helped bring were the numbers of civil society partners raising concern on the issue spread across different regions of the state. From a handful few now it is more than 150 civil society partners in the state working in all divisions to bring the issue to forefront. The turn around is also in their way of working from being a service delivery partners or a social mobilization partners in supportive and submissive role in a new avatar of advocacy partner. In this new role civil society speaks on the issue of right to health, its violation, demands state’s accountability to provide for safemotherhood. In this new business influencing people who make decisions which impact human lives is the key.

The primary target of the civil society was to bring the issues which impact lives of women at the villages, blocks and districts to the agenda of the people who make or influence decisions, i.e. state assembly debates, political leaders, members of legislative assembly, ministers, media, rights commission etc. They had been to some part successful. ex-pression of this concern was undertaken by directly meeting and sensitizing political leaders. The evidences highlighting gap were shared with political leaders, urging them to rise above politics and give a strong call for action. These non governmental organizations wrote memorandums, shared information and collected evidences for the same purpose. Media engagement also supported by providing an enabling environment for change. Strong evidences i.e. case of maternal deaths which can be presented, health system gaps were highlighted which added pressure on the state and the leaders to react. Resultant of this solid gains achieved. Today questions on maternal mortality are being raised in the state assembly, the highest policy making body of the state. It is not just few many voices are being publicly heard on the issue. There is a increased concern within media.

From nowhere it came to a point where state publicly acknowledge the problem, and its commitment to act. Many new polices and schemes have been announced and that too in the rapid succession. This amount of concern and even expressed publicly by leaders had never been seen earlier in the state on the issue of maternal mortality. But that is not enough today empowered civil society and media is always looking with eagle’s eye on the new measures of the state and vocally points out the gaps This is a positive sign, where people are voicing their opinion. But it is not easy as said. Political leaders have started picking up real cases of deaths, gaps in infrastructure in the state, violation of rights, gaps in policies and seeking answers to what is being done by the state to response to the situation.

Advocacy experts tell us that ‘people centered advocacy’ is the best, i.e. position when people who suffer can speak for themselves. A step has been taken in the same direction by the engaged networks. Madhya Pradesh Jan Adhikar Manch in their work with communities helped to bring the issue to debate in various gram sabhas which were held by panchayats in Gwalior – Chambal division. Similarly women who had participated in various women conventions hosted by Madhya Pradesh Samaj Sewa Sanstha came forward and wrote about the problems women face in rural areas when it comes to issue of safemotherhood and why do women die in their villages while giving birth. As per sources of Madhya Pradesh Samaj Sewa Sanstha more than 200 women have written to the Chief Minister. On a simple fifty paise post card, they wrote by theselves and it was send to the Chief Minister. It looks simple but powerful, if it gets to his eyes. Recently a large number of women from villages across Madhya Pradesh have joined a signature (or thumb-impression) campaign to press for their right to health and to call upon the Government to ensure that the dream of safe motherhood becomes a reality. As a part of a special drive to raise concern on this crucial issue, more than 20,000 women from different villages of the State are now in the process of signing (or placing their thumb impression) on a various banners demanding the right to health and calling upon the State to ensure that the dream of safe motherhood becomes a reality. Madhya Pradesh Voluntary Health Association, Madhya Pradesh Samaj Sewa Sanstha are the civil society partners who are collecting these signatures/thumb impressions of women. They say that they do so after they are adequately sensitizing them on the issue of maternal mortality. Then if they feel that some concrete action is needed to improve the situation, they come and sign. Plan is to present the banners with their signatures to policy makers.

One might say that this is good effort, which indeed it is to bring the agenda of maternal mortality on to the political and action framework but it is still a long way to go. This is true. But if one looks back one and half years where there was hardly any concern, hardly anyone called for action, except few that too ‘within the box’. The focus was limited. From nowhere it has come somewhere, which is an important achievement by any means. Need of the day is to provide possible answers to the state, which is willing to listen. Answers which can help deliver results, within the context of the field realties and socio – cultural aspects – a new call to many!


Lhamu, a mother of twelve, lives in a remote village in Western Tibet. Three of her children died within a month of birth and the four year old strapped to her back looked as small as a one year old. She gave birth all alone, at home, all twelve times. But Lhamu was lucky. She didn't die. One in 33 women dies during childbirth in Tibet. Malnutrition, abject poverty and lack of any health care – however basic—plagues Lhamu's family, as it does much of Tibet. Tibet – vast lonely stretches of dead habit with nary a creature on its harsh plains and no economy to speak of. It can't be as bad here in new economy India, right?

Think again.

One in 48 women in India is at risk of dying during childbirth. The Maternal Mortality Ratio (MMR) in India is a high 407 per 100,000 live births, according to the National Health Policy 2002. Other sources put the MMR at a higher 540 (NHFS and UNICEF data, 2000). Reducing the Maternal Mortality Ratio (MMR) by three-quarters by 2015 is a Millennium Development Goal (MDG) for all countries including India. Achieving this means reducing the MMR to 100 by 2015. Part of the problem is this measurement – MMR data is just not there and if it is, it varies widely depending on what method was used to get it.

Studies show MMR among scheduled tribes (652) and scheduled castes (584) is higher than in women of other castes (516, according to one study). It is higher among illiterate women (574) than those having completed middle school (484). The key determinant seems to be access to healthcare. Less-developed villages had a significantly higher MMR (646) than moderately or well-developed villages (501 and 488 deaths, respectively).

"It is very sad that the numbers are so high even 57 years after independence," avers Dr H Sudarshan who is Vigilance Director (Health) of the anti-corruption body Karnataka Lokayukta. "Not only are the numbers from the Sample Registration System (SRS) high, they are also incomplete. We do not know how many mothers actually died during childbirth and why. Underreporting is rampant and people hide MMR numbers in fear of repercussions. We need state-wise and within states, district-wise data," says Sudarshan who was also Chairman of the Karnataka Health Task Force which made wide-ranging recommendations based on a 2-3 year detailed study conducted in the state. Regardless, the UN MMR numbers for India (540) are several times higher than those for other developing countries like China (56), Brazil (260), Thailand (44), Mexico (83) or even Sri Lanka (92).

Medical reasons
So what exactly leads to such a high MMR? The main reasons for maternal deaths related to pregnancy are anaemia, post-partum bleeding and septic abortions with anaemia being the most rampant. "Antenatal care is most important," declares Sudarshan, "and that is just not being done. This kind of care checks for high risk pregnancies."

Public health advocate Dr Mira Shiva agrees, "Hypertension and the toxemias of pregnancy can only be detected with antenatal care. There is a total neglect of a mother's health in India. [The situation] is disgusting because a big chunk of all this is preventable. The medical establishment is busy with micronutrients but that is not the answer. Giving one iron tablet to a woman during her pregnancy is too late." Shiva is coordinator of the All India Drug Action Network (AIDAN) and one of the founding members of the People’s Health Movement (PHM). Striking out at a more endemic problem, she says, "The real problem is food. It is all about food, the cost of food and the nutrition content therein. These pregnant women have to fetch the water, make fuel, work the buffaloes, etc., all on the measly amount of food they can afford. How can the nutritive intake be enough? It becomes a negative calorie balance. In short, what is needed goes beyond a medical solution."

Sudarshan echoes Shiva's sentiment, "We need to move from a medical model to a social model. Nutrition for pregnant mothers is very important and the ICDS Anganwadi scheme has clearly not achieved the hoped results." Where antenatal care is good, the results are good as well. Kerala and Tamilnadu have good antenatal care and correspondingly have two of the lowest MMRs in India. In Assam and Bihar where antenatal care is almost zero, the MMRs are among the highest. India has the lowest percentage of antenatal coverage (60%) among countries like China, Brazil, Mexico, Thailand and Sri Lanka which are all in the high 86-95% range.

While antenatal care is paramount in the prevention of pregnancy-related deaths, septic abortions are more insidious. What is worse, the latter tends to go unreported due to the nature and circumstances surrounding it. In many rural areas couples do not use any spacing methods and women conceive within 7 months of having given birth. Dr Leena Joshi of Family Planning Association of India (FPAI) is familiar with this scenario. Her voice drops with concern when she mentions abortion rates in the remote reaches of Maharashtra. "The abortion rate in these areas is just so high. With it comes hidden mortality from septic abortion deaths. Since the PHCs do not have MTP methods, the abortions are performed by quacks. And even if the PHCs or district hospitals have MTP methods, the people opt for local help." Why? "It saves them money. These are very poor people and transport costs and medical costs can be saved by walking to a local quack." As a result there are a high number of abortion-related deaths which do not get reported under maternal mortality. Dr. Joshi laments that everybody only talks about deaths during the childbirth process. "But since there are so many septic abortion cases it all goes unreported."

The problem of unsafe abortion is something that Shiva worries about as well. "Abortion (MTP) being legal in India, no one is turned away. Second trimester abortion is a big reason for rising MMRs." People come late for the abortions and complications ensue. And apparently these are not only driven by spacing problems. "Contraceptives are used only by women and failure of these is common," says Joshi. Of course, abortion of female fetuses is routine and it goes on until the woman conceives a male child. The whole scenario makes one shudder.

But all this seems to be not even half the story.

Take malaria, for example. Orissa has a high incidence and accounted for 28.6% of detected cases of malaria -- 41% of falciparum -- and 62.8% of all material deaths in India (1998). Malaria and pregnancy form a sinister synergistic pair. Falciparum malaria leads to abortion and still births in the gravid woman and can severely compound anaemia. Coincidentally, Orissa has a high incidence of sickle cell anaemia. The combination is lethal. The haemoglobin in pregnant women could drop to 1gm/dL (healthy levels are between 12-16gms/dL). While drugs are available to treat the malaria, the treatment requires a high degree of awareness and care in administration. For example, the common primaquine and tetracycline are absolute no-nos during any stage of pregnancy. But chloroquine and quinine are allowed. "But mistakes occur and are lethal," says Shiva. Acting fast and carefully is paramount and any deaths due to these infections are primarily due to gross neglect or ignorance. Orissa has one of the highest rates of MMR in India at 738.

Another key reason for deaths during pregnancy is post-partum bleeding or haemorrhage. The need for blood in such cases is imperative and access is less than ideal. Both Sudarshan and Shiva worry about the blood bank policy in India. Heavily driven by the HIV/AIDS lobby, they feel that somewhere the important issue of access to blood has been sacrificed for quality and safety since the policy makers are looking at it all from the AIDS perspective. Says Sudarshan,"The policy says you have to keep the blood in an air-conditioned room. But in Coorg, for example, you don't need it. HIV awareness is good, but blood banks need to be demystified and access and availability improved." Shiva adds, "It is imperative in case of complications during pregnancy to have blood available. But no. NACO only sees blood banks from their perspective and only in an emergency are you allowed to take blood from the banks. It is a major concern." When it comes to donation, Shiva points to an endemic problem. The strange connection between men, caring for women, and giving blood. "If the men have to pay a lot of money and go far to get blood for their wives, they just won't. And men will never give blood. They think a 100 drops of blood equals one drop of semen and thus, giving blood is related to potency. And so many times, when women need blood, it is not available."

Organisational reasons
Early diagnosis of high-risk pregnancies and complications and quick referrals are of paramount importance. But is institutionalising deliveries the answer? By requiring 100% institutional deliveries, the World Bank supported vertical program Reproductive Child Health 1 (RCH1) resulted in the abolishing of the dais (Traditional Birth Attendants), and Sudarshan believes, probably increased MMR. Subsequently, following a public uproar, the program was amended to advocate "training" TBAs into Skilled Birth Attendants. "Institutional support will bring down MMR, yes, but what type of institution is important," says Sudarshan. "The so called Primary Health Care units are so dirty that infection will probably increase because of them." "In Bihar, for example," explains Sudarshan, "80% of the deliveries happen at home. In Karnataka it is 70%." Joshi concurs with this high degree of preference. "In the Bhandara area almost 100% prefer home deliveries. And if there are complications, it means there are inevitable delays in getting more sophisticated care."

Now, if there were a skilled birth attendant (SBA) at the time of each delivery or for antenatal checkups for each pregnancy, he or she can recognize a high-risk pregnancy or a potential complication and refer the mother to a district hospital or closest emergency care unit. The incidence of death from complications would be reduced. Countries like Malaysia have employed this strategy to bring down MMR to less than 100. In India only 43% of deliveries are attended by an SBA compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.

Sudarshan himself is involved in training tribal girls in the Soliga communities of Karnataka to be auxiliary nurse midwives (ANMs). For a population of 3000, there is a sub-centre and for every 5 or 6 sub-centres, there is a primary health care unit. Sudarshan's team trains the tribal girls in each village so that the few ANMs posted do not have to walk the 20 kms between the 4-5 villages this program covers. Joshi's team in Bhandara also trained 25 local dais or Traditional Birth Attendants (TBAs) to recognize complications and give basic medicines and obstetric care in the villages, one to each village. They also conduct antenatal checkups every month in about 10 villages. But funds for such programs are scant primarily because maternal health is not recognized as a priority issue in India. "The awareness that a pregnant woman should be taken care of is just not there," says Joshi. "If a woman is not delivering, the attitude used to be, let's wait and see, maybe tomorrow morning she will deliver. Now with our training, the dais can recognize complications but the money to shift the patient to a hospital is still not there."

This brings us to the next obstacle. So say the SBA refers to patient to an emergency obstetric care unit (EOC) and let's assume that we have one of those for every few villages. How would the patient reach the EOC? "Transport is a big issue. It is appalling that we do not have EMS (emergency medical services) that is efficient and well staffed," Sudarshan states categorically. He is working on building one for Karnataka with a coordinating body at district level which has jeeps, ambulances, even tractors available for responding to emergency calls. "We have to strengthen the PHC and an EMS is an integral part of that," he says. Bhandara is not so lucky. "Vehicles are available in 50% of the cases. But they are expensive. In the day, people can use buses, but not at nights. There are several rivers in this area and the buses are not allowed to travel over these at night," says Joshi.

Suppose the patient does reach the first referral unit (FRU) with complications that say, require a C-section. Is that a guarantee for a safe delivery? Sadly, no. Few FRUs run 24 hours. Joshi's hospital has 2-3 gynaecologists where the recommended number for the population of that area is 5-6. "All the C-sections and hysterectomies are carried out by these 2-3 gynaecologists. In the PHC in the villages, there is one doctor and 2-3 sisters (nurses), but they are only graduates, not post graduates or MBBS. So they cannot even do a complicated normal delivery, let alone C-sections."

Even in Karnataka, the FRUs are woefully understaffed and in some cases dangerously mismatched. "In one case," says Sudarshan with an ironic smile, "an orthopedist was posted where an obstetrician was required. With bribes, these so-called doctors can get posted to any area they want regardless of what is actually required there." And then there is the big problem of anaesthetists. At the Taluka level there is an acute shortage of them. Anaesthetists are required during complications and surgeries. When Sudarshan's team proposed that nurse obstetricians and other doctors also get trained in anaesthetics, the proposal was shot down by the medical lobby. Human resource management in the health sector seems to be a big issue. Shiva echoed the sentiment saying, "We need trained people in PHCs. And people with the right training. There is no point sending patients who require C-sections to where there is no anaesthetist or ob-gyn."

Government
Now, if we had fully staffed and functioning FRUs, would that bring down the mortality rate? Unfortunately, there is still one more layer that mothers have to contend with.

Shanta lives in a slum in Bangalore. When she was expecting her second child, she had the good fortune of being close to a government hospital where care would be free. Or so she thought. When she reached there, she realized that she had to 'buy' a bed or sleep on the floor. She also had to 'buy' food. So much so that she even had to 'buy' washing services or wear soiled clothes. And when it was time to "push" during delivery, she was just too weak, and the nurses slapped her. Left and right, again and again. They abused and cursed. "Is that the way to treat a patient?" Shanta queries in puzzlement. "My mother's house where I had my first born was better," she declared. Her sister-in-law Prema now laughs as she describes her own run-in with a local PHC outside Mysore. "They wouldn't give me my child until I paid up. Luckily I had saved all year, knowing this would be the case. The nurse was actually someone I grew up with. I thought she would be fair, but no. Everyone wants money." As soon as they got their money, she was sent home -– the same day -- with no medicines or follow-up monitoring either for her or her baby.

Corruption is not a new problem. "Even if the most sophisticated PHC is right across the road the ward boy needs to be bribed with Rs 150 to wheel the mother into the operation theatre and another Rs 300 to wheel her to the ward and most cannot afford that," declares a grave Sudarshan. In his opinion this final layer is the most important and toughest one to correct. "Bad governance. The real problem is not technological care but simply what I call the epidemic of corruption in the health services. And this is not just in the public healthcare sector, the private is just as bad," he says. "Doctors in Arunachal Pradesh take their pay checks but never show up. There is rampant corruption in procurement where, in one case, 123 spurious drugs were identified but bribes were taken and they were not reported. Dialysis machines which cost 5 lakhs are bought at 12.5 lakhs. Poor people end up spending huge amounts due to over-prescription of medicines that should be free to them. This is the real problem and no amount of infrastructure improvement will bring down MMR if governance is not improved," warns Sudarshan.

Shiva adds, "The private hospitals are mercenaries too. They perform unwanted C-sections and hysterectomies where none is required simply because there is big money in these procedures." Sudarshan, who sits in the anti-corruption cell of the Karnataka Government has presented strong recommendations to the Karnataka government regarding this issue. He stresses that good accreditation, accountability, good monitoring, and honest reporting are the only things that will actually bring down MMR, given the other necessities are taken care of.

And where will the money for the necessary infrastructure come from? Prime Minister Manmohan Singh has promised that the government spending on public healthcare -- which currently stands at an abysmal 0.9% of GDP (one of the five lowest in the world) -- will be increased to 2-3% of GDP which Sudarshan finds heartening, but tempers his optimism with caution. "It is great that there will be three times the amount available today for a sector that needs it badly, but one must plug the holes first. No point pouring all that money into a leaky vessel," he quips.

So, can it be done? Can MMR be brought down under 100 by 2015?

Sudarshan thinks so, but he will give it not 10, but 15 years. "It all comes down to political will. Sri Lanka, in spite of the civil war showed tremendous political will in tackling IMR and MMR and setting goals for themselves. Tamilnadu has a Deputy Commissioner (DC) monitor maternal mortality himself." This has increased the accountability and responsibility of the people in charge and has achieved good results. In Kerala, awareness about maternal health issues is high and the citizens demand more. Literacy plays a key role in keeping the MMR low. Kerala leads the way in successfully reducing MMR and Tamilnadu is close behind. While people like Sudarshan are doing everything to make sure it happens in Karnataka, the awareness and more importantly, recognition of this as an issue is lacking in other parts of India. In Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Assam and Orissa where the MMRs are well above the national average, it will require serious political will and accountability to change status quo.

The Ministry of Health and Family Welfare puts plans in place with the best of intentions (see here), but until governance and administration is addressed, people like Prema will still have no guarantees of care without paying beyond their means to like other pockets. But whether we will make progress will also be determined by when the Ministry recognizes MMR itself one of the key "Health and Population Indicators." Today, they do not. (See here.)

Both Shiva and Sudarshan agree that what India does not require is yet another vertical program to tackle maternal mortality. Verticals tend to be donor driven and cost intensive. MMR is not a disease unto itself. Clearly, high MMR is a symptom of a larger and wider problem in healthcare, namely the overall health of the woman, and should be treated as such and across verticals. Tackling a lot of the broader issues of governance and infrastructure should bring down the MMR. The National Rural Health Mission aims to reach across verticals to integrate services and by appointing an Accredited Social Health Activist (ASHA) at the community level provides decentralized first contact care. Shiva was part of one of the Task Forces of the NRHM and lauds its efforts as broadening the RCH program. But in order that the NRHM succeed, we come back to the need for evaluation methods and strong accountability.

The health of mothers is directly related to a child's health and without due attention to the causes behind high maternal mortality ratios, we are ignoring an important determinant of the health of our nation. In doing so, we may be running the risk of damaging our chances for all-encompassing prosperity.

Ways to tackle maternal mortality
To check the maternal mortality rate in India, health experts have stressed on changing the traditional treatment and delivery system being practised in most villages.

At the 52th All-India Congress of Obstetrics & Gynaecology, the annual meeting of The Federation of Obstetric & Gynaecological Societies of India (FOGSI), gynaecologists from across the globe advocated the need to adopt advanced strategies practised in some of the countries in Africa.

“Lack of access and inadequate utilisation of healthcare facilities are responsible for maternal deaths in India. Countries like Mozambique have made good progress in reducing maternal mortality ratio (MMR),” explained Staffan Bergstrom, from Sweden.

Bergstrom added that the healthcare facilities in remote areas of countries like India are virtually absent, with no specialist doctors and advanced treatment facilities.

“In a number of countries with low per capita income, there is a scarcity of specialist doctors. Non-specialist doctors do major surgeries and fail to diagnose complications. Besides, many medical and clinical officers are being trained to perform surgeries in remote places, where specialists are not available. This is very risky,” Bergstrom explained.

“We should remember that children’s health is directly related to mother’s health. The MMR reflect the health of our nation. So, we should introduce advanced facilities in our villages,” said Gita Ganguly Mukherjee, former head of obstetrics and gynaecology, RG Kar Medical College and Hospital.

In India, one of 48 expecting mothers is at risk of dying during childbirth. According to the data of National Health Policy 2002, the MMR in India is as high as 407 per 100,000 live births. Other sources have put the MMR as high as 540 (NHFS and Unicef data, 2000).

“The chances of death of an Indian mother during childbirth is roughly 10 times more than that of her Chinese counterpart,” said Bergstrom.

India and other Third World countries have set a goal to reduce the MMR by three-quarters by 2015.

Also Read:

Motherhood Cursed Bliss in India

Obstetrical Interventions and Maternal Mortality

Death in Birth

The Heartbrake

Telemedicine in Rural India

By M H Ahssan

In a developing country such as India, there is huge inequality in health-care distribution. Although nearly 75% of Indians live in rural villages, more than 75% of Indian doctors are based in cities. Most of the 620 million rural Indians lack access to basic health care facilities. The Indian government spends just 0.9% of the country's annual gross domestic product on health, and little of this spending reaches remote rural areas. The poor infrastructure of rural health centers makes it impossible to retain doctors in villages, who feel that they become professionally isolated and outdated if stationed in remote areas.

In addition, poor Indian villagers spend most of their out-of-pocket health expenses on travel to the specialty hospitals in the city and for staying in the city along with their escorts. A recent study conducted by the Indian Institute of Public Opinion found that 89% of rural Indian patients have to travel about 8 km to access basic medical treatment, and the rest have to travel even farther.

Can Telemedicine Bridge the Divide?
Telemedicine may turn out to be the cheapest, as well as the fastest, way to bridge the rural–urban health divide. Taking into account India's huge strides in the field of information and communication technology, telemedicine could help to bring specialized healthcare to the remotest corners of the country.

The efficacy of telemedicine has already been shown through the network established by the Indian Space Research Organization (ISRO), which has connected 22 super-specialty hospitals with 78 rural and remote hospitals across the country through its geo-stationary satellites. This network has enabled thousands of patients in remote places such as Jammu and Kashmir, Andaman and Nicobar Islands, the Lakshadweep Islands, and tribal areas of the central and northeastern regions of India to gain access to consultations with experts in super-specialty medical institutions. ISRO has also provided connectivity for mobile telemedicine units in villages, particularly in the areas of community health and ophthalmology.

This encouraging early success in reaching patients—together with recent technological advances in India, such as the proliferation of fiber optic cables, the expanding bandwidth, and the licensing of private Internet service providers—has encouraged ISRO to set up an exclusive satellite, called HealthSAT, to bring telemedicine to the poor on a larger scale. The proposed satellite would not only serve remote areas of India but also those in other poor countries in Asia and Africa. In the government of India's current budget, INR102.8 billion has been allocated for health. HealthSAT is expected to cost only about 1% of this budget, that is, between INR600 million to INR1 billion. Each receiving terminal (where patients and rural doctors are present for audiovisual conferences) in the villages is expected to cost only about INR0.5 million. This telemedicine service will save some costs, for example the money that patients would have spent on travel and accommodation.

A telemedicine system in a small health centre consists of a personal computer with customized medical software connected to a few medical diagnostic instruments, such as an ECG or X-ray machine or an X-ray scanner for scanning X-ray photos. Through this computer, digitized versions of patients' medical images and diagnostic details (such as X-ray images and blood test reports) are dispatched to specialist doctors through the satellite-based communication link. The information, in turn, is received at the specialist centre where experienced doctors examine the reports, diagnose, interact with the patients (along with local doctors), and suggest appropriate treatment through video-conferencing. The entire system is relatively user-friendly, and only a short period of training is needed for doctors at super-specialty centres and rural health centres to handle the system. And hospital technicians can take care of the operation and maintenance of the equipment.

M. N. Sathyanarayan, Executive Director of Space Industries Development, and organising secretary of the 2005 International Telemedicine Conference, said: “In the pilot phase of the telemedicine project, ISRO is providing telemedicine equipment as well as making available the required bandwidth on INSAT satellites. The main criteria for funding by ISRO are that the hospitals have to be government-run—state or central—or belong to public sector industries. The hospitals have to provide infrastructure as well as doctors and technicians for operating the system.”

“ISRO also provides the equipment and bandwidth to private specialty hospitals and hospitals run by Trusts, if these hospitals provide free service, including specialty consultation to rural hospitals that have been connected in the telemedicine network of ISRO. These hospitals have to provide follow-up treatment to teleconsulted patients at government rates.”

In its telemedicine initiative, ISRO intends to connect different types of Indian health care centers in a series of phases. L. S. Sathyamurthy, Programme Director of Telemedicine at ISRO said: “There are 650 district hospitals, 3,000 taluk [subdistrict] hospitals, and more than 23,000 primary health centers in the country. We must aim to connect all these in phases—first the district hospital connected to speciality hospitals in major cities, then the taluk-level hospitals, and finally the primary health centers, so that nobody, irrespective of his location, is deprived of lifesaving specialty consultation.” When the network grows, it may even include private hospitals as well as hospitals in Asia and Africa. Although the network will initially be used for teleconsultation and postoperative consultation, in the future it may accommodate even telesurgery and telerobotics.

The Impact So Far
Starting with pilot projects in the year 2001, together with a “proof-of-concept” technology demonstration, ISRO has established the facility in nearly 60 remote hospitals, which have been connected with 20 super-specialty city hospitals. A report presented at the Rajya Sabha (the House of States, or Upper House) of the Parliament of India suggested that the initial results of India's telemedicine initiative are encouraging. The report states that several telemedicine projects in India have been successfully interlinked—for example, the Andaman and Nicobar Islands telemedicine project links the G. B. Pant Hospital at Port Blair with Shri Ramachandra Medical College and Research Institute, Chennai, while in Karnataka, Narayana Hrudayalaya is connected to District Hospital, Chamarajnagar and Vivekananda Memorial Hospital, Saragur.

Adding to these early reports of successful linkage, there are also reports that telemedicine has helped to save lives in crowded pilgrimage centres and military outposts connected with mobile telemedicine units. For example, the Amrita Telemedicine Programme reports that on 13 January 2003, the programme's first remote telesurgery procedure was performed. The Amrita Emergency Care Unit at Pampa was able to save the life of a pilgrim by a telesurgical procedure using the local telemedicine facility. The cardiothoracic surgeon guided the procedure remotely, and the pediatric cardiologist at Pampa performed the procedure. Mobile telemedicine units were also rushed to the coasts and islands of India after the 2004 tsunami to provide medical consultation and relief to the affected people.

There are other indications that the telemedicine initiative may have had a positive impact. ISRO's annual report for 2004–2005 states: “More than 25,000 patients have so far been provided with teleconsultation and treatment. An impact study conducted on a thousand patients has revealed that there is a significant cost saving in the system since the patients avoid expenses towards travel, stay, and for treatment at the hospitals in the cities”. Dr. Devi Shetty, a cardiac surgeon and the Chairman of Narayan Hrudayalya, a hospital that has served thousands through telemedicine, said: “We have treated 17,400 patients using telemedicine connectivity in various parts of India, mainly from rural India, and [a] few patients from outside India. We use both satellite as well as ISDN connectivity. Now, with the Indian Space Research Organisation, which is our associate in this project giving us the satellite connection free of cost, we have a [larger] game plan of offering health care to African and other Asian countries.”

The Challenges and Controversies
The telemedicine initiative in India has not been free of challenges and controversies. “There are inevitable difficulties associated with the introduction of new systems and technologies,” according to Sathyamurthy. “There are some who needlessly fear that they will lose their jobs. Although the systems are user-friendly, there are others who are affected by the fear of the unknown in handling computers and other equipment. There is a feeling that the initial investment is high and hence financially not viable.” In addition, there may be technical hitches, such as low bandwidth and lack of interoperability standards for software.

Discussing HealthSAT, Dr. D. Lavanian, an Indian expert in telemedicine affiliated with the Apollo Telemedicine Networking Foundation, Apollo Hospitals, Hyderabad, India, said: “[HealthSAT] is excellent, but some questions remain. Presently HealthSAT connectivity is expected to be given free of charge to certain government entities. This is unsatisfactory as a large percentage of health care in India is by private entities.” Dr. Lavanian added: “On my requesting to ISRO to open up the same to the private health industry, of course for a fee, I have not received any positive answer. This means that a large percentage of the population of India will be denied healthcare via telemedicine.”

These difficulties can probably be surmounted. In the late 1980s, when computers came to India, similar kinds of problems were seen in different parts of the country. That is, people showed technophobia and expressed their fears that computers would cause unemployment and would also be prohibitively expensive. But the country overcame these challenges and fears, and eventually became a superpower in the field of knowledge and information technology.

With the aid of HealthSAT, India's telemedicine initiative has the potential to provide specialized health care to millions of poor Indians. This potential was well summed up by Dr. Devi Shetty: “In terms of disease management, there is [a] 99% possibility that the person who is unwell does not require [an] operation. If you don't operate you don't need to touch the patient. And if you don't need to touch the patient, you don't need to be there. You can be anywhere, since the decision on healthcare management is based on history and interpretation of images and chemistry … so technically speaking, 99% of health-care problems can be managed by the doctors staying at a remote place—linked by telemedicine.”

Event Live: What Will Healthcare Look Like in 25 Years?

By Dr. David Katz / New York

The Aspen Ideas Festival, an annual event in which I had the privilege of participating several years back, is now convening in that rarefied Rocky Mountain air. Those heights perfectly suit the venue, in which thought and idea, examination and exhortation, are intended to take flight.

As they do so, one of the more popular destinations is, inevitably, the future. Even our scholarly examinations of history are of greatest current relevance in helping us sidestep repetition of well-worn folly. The deep thinking we do today is frivolous and futile unless it informs potential action, and cultivates favored opportunity. The Ideas Festival is willfully, and all good ideas are perhaps ineluctably, tangled up with tomorrow.

‘Trumpcare’ Is Dangerous to the American Healthcare System

Congressional efforts to do away with Obamacare threatens leaving millions of Americans without any health insurance.

The American healthcare system is in danger. The Senate’s new Bill, the Better Care Reconciliation Act (BCRA), released in June, is an effort by the Republican Party to “repeal and replace” the Affordable Care Act (ACA), or ‘Obamacare,’ put forward by the Barack Obama administration.

Healthy Business: Will Medical Tourism Be India’s Next Big Industry?

No Other Choice: Why Medical Tourism Continues to Thrive: President of the United States Barack Obama recently urged Americans to seek medical treatment at domestic health care facilities, rather than traveling overseas. In India, where so-called "medical tourism" (known internationally as the global health care delivery system) is a booming industry, his statements have created quite a stir. In this opinion piece, Ravi Aron, a professor at Johns Hopkins University and a senior fellow at the Mack Center for Technological Innovation at the University of Pennsylvania, argues that people can't take advantage of something that doesn't exist. Until affordable universal care is a reality in the U.S., Aron says, Americans will continue to travel abroad for health care services.

President Barack Obama has asked Americans not go to India and Mexico for medical treatment. There are reasons why these appeals will have no impact on global health care delivery. Patients do not travel to India for health care services because they have a choice and they choose to go to India. They travel to India because they have no choice. They are either uninsured or grossly under insured and they cannot afford the cost of care in the U.S.
If a consumer exercises choice -- among comparable options -- then he or she can be asked to buy American. But the choice that these consumers of global health care services face is between care delivered overseas (Mexico, India or elsewhere) and no care at all. So asking them to stay in the U.S. is pointless. Until affordable universal care is a reality in the U.S. they will continue to travel abroad for health care services. This is not a discretionary spending that they can postpone or redirect.

Characteristics for Success
The globalization of health care services is inevitable in this environment. What are the characteristics needed for the industry to flourish? Look at it at the level of the multi-specialty hospital. The hospital needs to address the patients' sense of risk. If somebody in frail health is going to fly 12 hours to reach a point on the other side of the globe to get a bypass surgery or a hip replacement done in a country that they know very little about and one with a strange culture, they experience anxiety that stems from risk. Most of us weigh the choice of a vacation destination carefully; these people are literally entrusting their lives and well-being to a hospital and doctors that they do not know. So this is a decision that is characterized by a great deal of risk. Hospitals like Bumrungrad in Thailand go out of the way to address this risk. There are four levels at which they do this:

The Four Levels of Addressing Risk
The physical environment: The hospital lobby and the building feel like an excelsior hotel in a first world country. They go out of the way to showcase the sense of order and calm that prevails everywhere. The western patient would instantly feel at home with the Starbucks Café and Wi-Fi-enabled waiting lounges. The hospital and its lobby, lounges and wards gleam in their antiseptic cleanliness.

Process discipline: Bumrungrad hospital is pretty close to what we call a 360-degree automated hospital. From the point the patient has been admitted (from his overseas location) till discharge, all processes are centrally linked to the patient's records and care delivery, and support services are delivered and monitored at the level of each patient. They have extraordinary efficiency in the way they support clinical care with other services -- travel, hospitality (accommodation), transport within the city, billing and post-procedure follow-up.

Excellence in clinical care: Many of their doctors are board certified in the U.S. and in Thailand and Bumrungrad was the first hospital to get the JCI [Joint Commission International] accreditation in the region. On most parameters of medical care -- these statistics are available at the hospital site -- they compare more than favorably with the median hospital in U.S. and the E.U. (They were in the 90th percentile in patient satisfaction scores compared to similar hospitals in the U.S. and Europe).

Strategic use of IT: They use IT both to offer fine-grained information about the hospital, treatments and procedures at the hospital, and physician background to overseas patients, as well as information as a tool for monitoring and delivering clinical outcomes.

In terms of clinical information, they have been able to automate three crucial elements of clinical information flow: (i) Physician-level information from multiple physicians attending on the same patient; (ii) Information from clinical sources pertaining to a patient (tests, labs, nurses and clinical support services); and (iii) patient case history. This, in turn, has allowed them to implement a variety of innovations in care delivery that minimize medical errors, infection rates, etc. It also allows them to monitor patients and their progress in fine-grained detail. (Automating these three kinds of clinical information flows is very critical not only to deliver higher quality of care, but also to create "patient information portals" where the patient can constantly access his or her EHR (electronic health record) after the procedure from his or her country of origin, as well as schedule repeat check-up visits. Automating these three kinds of information flows is one of the reasons that Bumrungrad is referred to by some as the "gold standard" in global health care delivery).

First World Skills in Emerging Regions
So why is all of the above important? These are first-world institutions of skill and service excellence located in developing regions. The developing region economics makes these regions attractive from a cost (price) standpoint to overseas consumers. The first world skills and service excellence makes them attractive from the standpoint of actual care delivered to patients. For the paying patient, it is important to signal that the hospital is an island of calm and order founded on a reliable first world infrastructure and where care delivery is monitored with great precision and discipline. The patient needs to feel that this hospital has been insulated from its environment.

India is not lacking in clinical skill (quality of physicians). Traditionally, Indian hospitals were seen as weak in post-procedural care delivery (sometimes referred to as "post operative care"). But that, too, is changing. Some hospitals are beginning to get their acts together on post-procedural care in terms of significantly lowering medical errors and hospital infections, and improving nurse and support clinician hygiene standards. There is still much that can be done in this regard.

An area that is often overlooked by the Indian care delivery establishment is that of support services: travel, logistical support, accommodation and hospitality, transport within the destination city, billing, etc. Overseas patients are probably comfortable with the quality of Indian physicians; they are more concerned with clinical post-procedural care, support services and the infrastructure.

Medical services in India are where the IT-enabled services and the business process outsourcing (BPO) industries found themselves in the mid 1990s -- the challenge is to convince the customers that these hospitals are islands of excellence that have been insulated from the frailties of India, even as they draw upon its strengths. These services are not branded as "made in India" as much as "made in spite of India."

The Advantages of India
The one advantage the country has is that a doctor in India -- especially a surgeon -- would have acquired in 10 years' time more experience -- both in terms of scale of procedures done and the exposure to varying levels of complexity -- than what a surgeon in the U.S. would get in, say, 30 years of practice. So a doctor with about 15 years experience will probably be unrivalled in the scope and scale of his exposure.

In the well-run hospitals and multi-specialty centers, they have deep reservoirs of capability to treat patients who come in for a procedure with comorbidities [the presence of one or more disorders in addition to a primary ailment]. Not only can they perform the procedure, but they can also deliver related chronic care where necessary (procedure plus care for cardiovascular disease, diabetes, etc). Specialists are readily available to deliver care for comorbidities from a single location.

Almost all these institutions are private hospitals that cater to the needs of India's wealthy, powerful (Anglophone) elites. They are used to delivering services to a demanding clientele. This serves them well with overseas customers. A large number of physicians in the U.S. and the U.K. and in some Gulf countries are of Indian origin. So, overseas patients do not have the problem of entrusting themselves to Indian doctors.

The doctors of Indian origin can also serve as a distribution channel of sorts to hospitals in India. These institutions can tie up with these doctors to deliver some measures of post-procedure diagnostic care and ongoing care in the countries of origin of the patients.

The Low Cost Is a Given
The other advantage is, of course, cost. But there is no need to stress the difference in costs. The patient is usually acutely aware of the difference in the sticker price for care. The multiples range from eight to one to three to one, even after factoring in travel and other non-clinical costs. There is no reason to draw attention to this. It is far better to highlight capabilities and excellence for two reasons. First and less important, is that this will translate into "capabilities and excellence at an affordable cost" in the patient's mind. Second, and more important, the patient is worried about capabilities and support care and the risk of entrusting his life and well-being to a strange system far away from his home. So it is vital to address those concerns rather than emphasize "cheap." The patient is all too aware of the cost difference anyway.

Finally, the use of web-based channels to inform potential patients is key to running an efficient marketing operation. Hospitals should be able to offer information about JCI certification, physicians' experience and qualifications, the depth of their capabilities in performing specific medical procedures (coronary bypass, hip replacements, etc.) and give patients an accurate estimate of the costs.

Bumrungrad's use of electronic channels is a case in point in effective marketing. The hospital has developed a cost simulation where the patient can key in details of his or her condition and the simulation gives a clear estimate of the cost frontier that he or she will face: it gives the patient a distribution of costs that similar patients in the past faced -- including an average, a high percentile and a low percentile number -- allowing the patient to form his or her own estimate of the costs of care. This electronic estimate is based on actual costs of past patients and it is constantly updated from the hospital's database. Bumrungrad is able to do this because every element of the final cost the patient pays is itemized and categorized in the final invoice. This is yet another example of their strategic use of IT to both serve the customer and market their services effectively.

In the past, U.S. President Barack Obama has singled out India for what he sees as the country usurping American jobs and business. In May 2009, he removed some tax incentives for U.S. companies who allegedly preferred to outsource rather than create domestic jobs. "Buffalo before Bangalore" was his rallying call at the time. Now, India is back in his crosshairs. In April 2011, he told a town hall gathering in Virginia that Americans shouldn’t have to go to India or Mexico for “cheap” health care. "I would like you to get it right here in the U.S.," he said.

"It’s a 100% political statement," Gopal Dabade, convener of the All India Drug Action Network, told weekly newsmagazine India Today. Others in India were equally critical and dismissive. But some have taken more serious objection. "Not acceptable," says federal health minister Ghulam Nabi Azad. Affordable health care does not mean our medicine is inferior to any superpower’s. I would like to say our medicines are indigenous, they are superior, and superiority does not come by escalating costs."

The bone of contention is the word "cheap." Obama probably used the term in the sense of less expensive. But Indians have interpreted it as meaning "tawdry and inferior." Analysts don’t expect Obama’s political posturing to make any difference to the flow of U.S. medical tourists into India. But there is a lurking fear, nevertheless, that a nascent sector could be hamstrung at birth.

There Is No Choice
"Patients do not travel to India for health care services because they have a choice and they choose to go to India," says Ravi Aron, professor at the Johns Hopkins Carey Business School and a senior fellow at The Mack Center for Technological Innovation at Wharton. "They travel to India because they have no choice." Adds Rana Mehta, executive director, PricewaterhouseCoopers (PwC) India: "If patients see value in what India has to offer, they will continue to come."

Indians feel aggrieved that they have been singled out. In medical tourism, the country is still a bit player. According to a report by the Delhi-based RNCOS, which specializes in Industry intelligence and creative solutions for contemporary business segments, India’s share in the global medical tourism industry will reach around 3% by the end of 2013. The December 2010 report -- titled "Booming Medical Tourism in India" – says that the industry should generate revenues of around US$3 billion by 2013. "The Indian medical tourism industry is currently in its early growth stage," says RNCOS chief executive Shushmul Maheshwari.

Guess who’s the biggest beneficiary of medical tourism? It’s the U.S. "The largest segment, with 40% of all medical travelers, seeks the world’s most advanced technologies," says a McKinsey & Co paper titled "Mapping the market for medical travel." "These men and women take their search for high-quality medical care global, giving little attention to the proximity of potential destinations or the cost of care. Most such patients travel to the U.S." What worries the Indian industry is that this is not the first attack on Indian medical tourism. In August last year, leading medical journal The Lancet had published an article about a new superbug which it called the New Delhi metallo-beta-lactamase 1 (NDM-1). "The potential of NDM-1 to be a worldwide public health problem is great, and coordinated international surveillance is needed," said the article. Later, a co-author noted that some material had been inserted into the article without his knowledge; the editor of The Lancet had to apologize for naming the bug after New Delhi, and the Indian ministry of health had to weigh in. "The conclusions are loaded with the inference that these resistance genes/organism possibly originated in India and it may not be safe for U.K. patients to opt for surgery in India," said the ministry. "The medical journal's claim is not supported by any scientific data and thus tarnishes the reputation of the country." Rightly or wrongly, the government and many in India’s medical establishment believe that naming the superbug New Delhi was to keep U.K. medical tourists at home. "The superbug certainly garnered a lot of media attention given its name," says Preetha Reddy, managing director of Apollo Hospitals.

It won’t keep medical tourists at home, just as Obama’s appeal is likely to be ignored. "People will always weigh the cost and the benefit," says Reuben Abraham. "If there is a 10% saving and there is a danger of the superbug then chances are that people will not want to take it. But if you are offering an 80% discount, it is a different matter. If India continues to offer high quality health care at one-tenth the cost in the U.S. then these things will not make an impact."

The Next Big Thing
If all this is going to have limited impact, why is India getting so agitated? The answer lies in the potential of medical tourism. It could easily be the next big thing. Unlike business process outsourcing (BPO), which is on the whole very low-tech, health care -- particularly sophisticated procedures -- is very high-tech. India has not been able to set up an adequate health care infrastructure for its own citizens and it doesn’t have the money to do so. Creation of a sophisticated medical tourism structure will have a trickle-down effect.

"India has the highest potential in medical tourism in the world," says Maheshwari of RNCOS. "Factors such as low cost, scale and range of treatments differentiate it from other medical tourism destinations. Moreover, growth in India’s medical tourism market will be a boon for several associated industries, including the hospital industry, the medical equipment industry, and the pharmaceutical industry."His study shows that CAGR (compound annual growth rates) in revenue in 2011-13 will be 26%. In terms of medical tourists, the number would touch 1.3 million by 2013 at a CAGR of 19%. "Medical tourism can be considered one of the rapidly growing industries in the Indian economy on the back of various factors," he says. "However, the industry is at a nascent stage and requires a few years to reach the platform already established by the IT sector." "India has been ranked among the top five destinations for medical tourism," says Rana Kapoor, founder, managing director and CEO of Yes Bank, which has recently done a study on health and wellness tourism in India along with apex chamber of commerce FICCI.

The ranking by Nuwire Investors, an online source for news on alternative investments, puts Panama on top, followed by Brazil, Malaysia and Costa Rica. "India is looking at exponential growth as far as tourism is concerned," continues Kapoor. "Yes Bank forecasts that there will be an increase in domestic tourist movements over the period (2008-2020) by 118% and foreign tourist inflows over the same period will increase by 71.87%. What the potential for medical tourism from within this growth rate of 71.87% will be depends upon government policies, faith of the patients and many other external factors. We truly believe that this sector will play a significant role as a contributor towards the overall tourism growth in India."

"I strongly believe that many developments across the world will put India in a fantastic position," says Devi Shetty, cardiac surgeon and chairman of Narayana Hrudayalaya. "We produce the largest number of doctors, nurses and medical technicians in the world. Also, we have been traditionally linked with western health care because of the British influence on our medical education and the ability to speak English. This is extremely important for developing [global] health care. Our greatest asset is our ability to produce the largest number of technically-skilled individuals. We also have the largest number of USFDA (U.S. Food and Drugs Administration)-approved drug manufacturing units outside the U.S."

Differences over Terminology
Shetty doesn’t like the term medical tourism. "Medical care is something that is very stressful and people consider this under tremendous pressure," he says. "It is an event where people are scared of losing their lives. It may not be appropriate to call it tourism. Tourism is a different business altogether." Adds Mehta of PwC: "The tourism component is really very weak. Most foreign patients come to India for chronic and serious medical treatment and I would call it medical value travel." Aron of Johns Hopkins has yet another view. "The world over it is known as the global health care delivery system," he says. Reddy of Apollo agrees with Mehta. Says she: "At Apollo Hospitals, we prefer to term this business opportunity as ‘medical value travel’ as people travel to our hospitals for serious life threatening health conditions, which essentially need highly skilled doctors and medical infrastructure and not mere minor treatments like cosmetic enhancements, dental work or wellness which can be coupled with holidays, as the term ‘medical tourism’ implies."

The multiplicity of names is accompanied by a wide range of numbers. The confusion was started by the McKinsey study on Mapping the Market mentioned earlier. The May 2008 report said that "medical travel has captured the world’s attention and imagination". But it went on to explain that the McKinsey definition of medical traveler was very different from what many others thought him to be. The first to be knocked off were expats looking for health care in their country of stay. That accounted for 25-30% of the traditional medical tourist pool.

Then was the segment categorized under emergencies. These were ordinary tourists caught up in accidents. That eliminated another 30-35%. McKinsey estimated the remaining at "between 60,000 and 85,000 inpatients a year", much lower than generally accepted numbers. For instance, a 2008 Deloitte Center for Health Solutions report on "Medical Tourism: Consumers in Search of Value" put the number of Americans who had traveled abroad for medical care in 2007 at 750,000. McKinsey excludes "wellness" tourists (acupuncture, spas, yoga, aromatherapy and the like), patients from neighboring countries, and outpatients -- those who don’t need to check into hospital.

The Deloitte report says that India is stepping on the gas; the medical tourism sector is expected to grow 30% annually up to 2015. An update on the report says that the U.S. recession is driving more people out of the country for health care; U.S. outbound medical tourism is projected to increase 35% annually from 2010-2012. "Medical tourism [today] represents the maturation of a cottage industry," the report sums up.

Maheshwari of RNCOS agrees that economic problems are driving more Americans abroad for health care. "Under almost stagnant salary increments, the disposable income and saving considerations of U.S. citizens are still well below the pre-crisis levels," he says. "In this scenario, the low cost treatment and nearly zero waiting time coupled with its proven track record offer convenient procedures for tourist arrivals from various geographical locations including the U.S."

"Over the past few years, the medical tourism story has changed dramatically in India," says a recent Cover Story in weekly business magazine BusinessWorld. (That it made it to the Cover is a reflection of the growing importance of the sector.) "Not because the government has figured out the solution. But purely because of private enterprise -- with a few corporate hospitals, chemists and freelance agents all working in tandem to build a thriving ecosystem that educates, facilitates and ferries medical tourists from across the world. Last year, this ecosystem was responsible for about 600,000 patients travelling to India and spending US$1 billion in getting treated here. (The numbers are industry estimates as the government does not have any official statistics on the subject.) Corporate hospitals such as Apollo, Fortis Hospital and Max as well as business associations estimate that the business is growing by 40% year-on-year." (Obviously, the growth numbers vary depending on who you talk to.)

Other Markets Will Turn to India
"India’s potential is huge," says Mehta of PwC. "Some 80% of foreign patients coming to India are from the neighboring countries and from Iraq, Afghanistan, the former Soviet Union, etc and now increasingly from Africa. But now with India proving itself as a credible provider of value health care, the western population ageing, and health care becoming more difficult there, I expect more people to come from the U.S. and the U.K."

Mehta says that some things went wrong with the earlier planning. "We expected most patients to come from the U.S. and Europe. We expected people to come for cosmetic and regenerative treatment and this is where there is more potential for tourism. But the majority actually came for cardiac treatment, cancer treatment, knee replacement and other serious ailments. Therefore, tourism was not really of importance. We did not get the cost factor right. We thought that typically in India it costs one-tenth of that in the U.S., so we could cost at 5X. But hospitals have not been able to charge very much. At present, with a foreign patient, there is around 20% more earning."

Cost is, of course, being underplayed in the marketing efforts; this is why the word "cheap" rankles. "The patient is usually acutely aware of the difference in the sticker price for care," says Aron. "There is no reason to draw attention to this.”That’s an area where India enjoys an advantage over other countries too. According to the BusinessWorld report, a heart bypass surgery costs US$144,000 in the U.S., US$25,000 in Costa Rice, US$24,000 in Thailand, US$20,000 in Mexico, US$13,500 in Singapore, and US$8,500 in India. "The quality is excellent," says Maheshwari. In India, there is also less waiting time and personalized services.

Becoming an Industry
Medical tourism is also taking shape as an industry, though there are some who feel that it will eventually fall in many buckets. (The recent FICCI-Yes Bank study talks of wellness tourism, health tourism...) "There are over 3,371 hospitals and around 750,000 registered medical practitioners," says Maheshwari.

Shetty says it is easier to get loans these days. "Earlier, it was difficult for us to mobilize huge financial support to create large hospitals. However, things have changed now," he explains. Indian companies are also taking over hospital chains in Asia -- Fortis has gone on a shopping spree, though it’s not been entirely successful -- and setting up front-ends in other countries for marketing purposes. Apollo has facilitation centers in Oman, Nigeria and the U.S. Max is present in Nigeria, Afghanistan, Bangladesh and Nepal. Says Reddy of Apollo: "There are several key players. Apollo Hospitals continues to attract the largest numbers of international patients followed by Max, Fortis and Workhardt."

"Another opportunity that Indian operators are now seeing is that you don’t have to offer these health care services from India," says Abraham of ISB. "For instance you can offer it from say, Cayman Islands or the Bahamas. Ultimately, the innovation is in the process and as long as you can bring the same process innovation, even if the cost goes up a little as compared to offering it from India, it will still be a substantial saving for the patient."

This is one area where China is no threat. Foreigners in China still rush to Hong Kong when they need treatment because they cannot communicate with local doctors.

But what the budding sector will have to contend with is the Indian government. Take one example. With the intention of making things smoother, the government introduced a medical visa (M visa), which was faster and easier to get. In its wisdom, however, it added a peculiar clause -- "Foreigners coming on M visa will be required to get themselves registered mandatorily well within the period of 14 days of arrival with the concerned Foreigners Regional Registration Office." The end result: even patients who have to be carried into India on stretchers are coming on tourist visas. If the government wants medical tourism to be the next big thing, it has to put its house in order.

As for the immediate controversies, Shetty is very clear. "President Obama’s statement or the New Delhi superbug will not affect medical tourism development in India," he says. "First of all, he was not criticizing India. He was just trying to put his house in order."