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3.1 HEALTHCARE SCENARIO IN INDIA


3.1.1 Overview Indias health system can be categorized into three distinct phases31:
a) In the initial phase of 1947-1983, health policy was assumed to be based on two broad principles: (i) that none should be denied healthcare for want of ability to pay, and (ii) that it was the responsibility of the state to provide healthcare to the people. This phase saw moderate achievements. b) In the second phase of 1983-2000, a National Health Policy was announced for the first time in 1983, which articulated the need to encourage private initiative in healthcare service delivery and encouraged the private sector to invest in healthcare infrastructure through subsidies. The policy also enhanced the access to publicly funded primary healthcare, facilitating expansion of health facilities in rural areas through National Health Programmes (NHPs). c) The third phase, post-2000, is witnessing a further shift and broadening of focus; the current phase addresses key issues such as public-private partnership, liberalization of insurance sector, and the government as a financier.
Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, August 2005
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The National Health Policy, 200232 outlines improvement in the health status of the population as one of the major thrust areas in social development programme. It focuses on the need for enhanced funding and an organizational restructuring of the national public health initiatives in order to facilitate more equitable access to the health facilities. The National Common Minimum Programme identifies health as an important thrust area. The Government is in the process of raising the public spending on health with focus on primary healthcare. As a result of various initiatives, India has registered significant progress in improving life expectancy at birth, reducing mortality due to Malaria, as well as reducing infant and maternal mortality over the last few decades. The rural primary public health infrastructure has increased and now India has around 145,000 Sub-health Centres, over 23,000 Primary Health Centres and around 4000 Community Health Centres, catering to a population of 5,000, 30,000 and 1,00,000 respectively33. However, only about 20% of healthcare services are being provided by public sector, with the remaining being provided by the private sector. It is also estimated that about 10% of population is covered by any form of health insurance. Private healthcare is expected to continue as the largest component (Rs. 156,000 crores) of healthcare spending in 2012, and could reach Rs. 195,000 crores with broader coverage of health insurance34. According to a study by KSA Technopak, private sector plays a major role in servicing the Indian healthcare market; more than 90% of it is being served by the urorganised sector. However, transition is expected to happen in the healthcare industry, with more and more corporate players are entering the business in an organized way. It is also estimated that increase in income levels,

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Ministry of Health and Family Welfare, Government of India; http:// mohfw.nic.in/np2002.htm

33 Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India 34

Healthcare in India: The Road Ahead, CII-Mc Kinsey & Co.; October 2002.

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increase in share of population with lifestyle diseases, increasing penetration of insurance market, especially the health insurance segment are important reasons for more number of organized players entering in the market. Exhibit 14 depicts increasing share of private sector in Indias healthcare market over the years. Tables 6 and 7 illustrates the healthcare profile of India, and the density of health workers in India, respectively.
Exhibit 14: Increasing Share of Private Sector in Indias Healthcare Market

Source: Ten Industry Trends: 2007, Healthcare Outlook, KSA Technopak, Volume 1, February 2007.

3.1.1.1 Healthcare Education and Research The Government has set up regulatory bodies with the objectives of monitoring the standard of medical education, and promoting training and research activities in the country. The overall objective is to sustain the production of medical and para-medical human resources to meet the requirement of healthcare delivery system in India. Regulation of medical education and profession in India is given in Exhibit - 15.

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Sl. No 1 2 3 4 5 6 7 8 9 10

Table 6: Healthcare Profile of India Description


Total Expenditure on Health as % of GDP (2003) Government Expenditure on Health as % of Total Expenditure on Health (2003) Private Expenditure on Health as % of Total Expenditure on Health (2003) Government Expenditure on Health as % of Total Expenditure (2003) External Resources for Health as % of Total Expenditure on Health (2003) Social Security Expenditure on Health as % of General Government Expenditure on Health (2003) Out of Pocket Expenditure as % of Private Expenditure on Health (2003) Private Prepaid Plans as % of Private Expenditure on Health (2003) Per capita Total Expenditure on Health at Average Exchange Rates (US $) 2003 Per capita Government Expenditure on Health on Average Exchange Rates (US $) - 2003

Data 4.8% 24.8% 75.2% 3.9% 1.6% 4.2% 97.0% 0.9% 27.0 7.0

Source: Working Together for Health, World Health Report, 2006; World Health Organisation, 2006.

Categories

Table 7: Density of Health Workers in India Year Number Density per 1000
2005 2004 2004 2004 2003 1991 2004 1991 2005 645285 865135 506924 61424 592577 325263 50393 15886 818301 0.60 0.80 0.47 0.06 0.56 0.38 0.05 0.02 0.76

Physicians Nurses Midwives Dentists Pharmacists Public and Environmental Health Workers Community Health Workers Lab Technicians Other Health Workers

Source: Working Together for Health, World Health Report, 2006; World Health Organisation, 2006.

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Further, Indian Council of Medical Research (ICMR) has been set up as an apex body for planning, organization, implementation and coordination of medical research in the country. In addition, there are plethora of institutions for education and research in the healthcare sector.
Exhibit 15: Framework for Medical Education / Regulation in India

3.1.2 Role of Private Sector in Healthcare India is encouraging investment in healthcare sector; over the years, the private sector in India has gained a significant presence in all the sub-segments of medical education and training, medical technology and diagnostics, pharmaceutical manufacture and sale, hospital construction and ancillary services, as also the provisioning of medical care. Over 75% of the human resources and advanced medical technology, 68% of an estimated 15,097 hospitals and 37% of 623,819 total beds in the country are in the private sector35. The composition of private sector in India is diverse with large number of sole practitioners or small nursing homes having bed capacities of less than 20. There are also several corporate entities, including pharmaceutical firms, and non-resident Indians (NRIs),

35 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, August 2005

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who have invested in the Indian healthcare sector and are providing world-class care at a fraction of the cost compared to many developed countries. In addition, there are also traditional healthcare providers, such as Ayurveda and Yoga, who have set up facilities. It is reported that there are 1369 hospitals with a bed capacity of over 53000 in India catering to the needs of traditional Indian healthcare; about 726,000 registered practitioners are working under the traditional healthcare system36. Indian hotels are also entering the wellness services market offering Spas and Ayurvedic massages, tying up with professional organizations in a range of wellness fields.

3.1.3 Health Insurance According to Insurance Regulatory and Development Authority (IRDA), health Insurance is one of the fastest growing portfolios of general insurance business37. In order to give a special focus to this area, the IRDA is in the process of setting up a separate Health Insurance department. IRDA is also planning to bring out separate regulations/guidelines for health insurance.
Penetration of health insurance in India is low; health insurance is estimated at around 10% of total population. However, majority of the health insured in India are covered under social health insurance or community-based health insurance, and the penetration of commercial insurance may be around 1% only. The reasons for low penetration of commercial health insurance is due to low level of innovation in health insurance products, exclusions and administrative procedures governing the policies, and chances of co-variate risks, such as epidemics, which keeps the premiums high. Following the enactment of IRDA Act, 1999, Third Party Administrators (TPAs) are facilitating the healthcare insurance penetration. The prime role of TPAs is to provide the back office
36 Department of AYUSH, Ministry of Health and Family Welfare, Government of India; http://indianmedicine.nic.in/summary-of-infrastructure.asp

Annual Report 2005-06, Insurance Regulatory Development Authority, December 2006.

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administrative set-up to insurance companies such as issue of identity cards, processing of claims and settlement of bills. Performance of TPAs in terms of claims settled in India is given in Table 8. However, TPAs have also helped in facilitating a large number of policy holders in getting cashless medical treatment in hospitals. Some TPAs are enhancing their role to provider networks to service other needs of the insured. With such enhanced role, the insured are getting a feel of managed care, relieving the patients from the psychological stress of filling various forms and mobilizing resources at short notice. Thus, in the long run, the role of TPAs is likely to bring down the cost of medical treatment in the country. There are, at present, over 25 TPAs (Box 9), and majority of the general insurance companies that are transacting health insurance business have empanelled them for servicing their policies. The list of hospitals empanelling TPAs is also expanding, showing greater confidence reposed by both the hospitals as also the insurance companies.
Table 8: Third Party Administrators Claims Data in India Claims Received Claims Settled (Number) (Number)
Within Within Within 1 month 1-3 months 3-6 months 1126895 730269 (64.80) 291766 (25.89) 36051 (3.20) More than Claims 6 months outstanding 10597 (0.94) 104740 (9.29)

NB: Figures in brackets indicate the ratio (in per cent) of claims settled to the total claims received Source: Annual Report 2005-06, Insurance Regulatory Authority of India, December 2006

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Box 9: List of Third Party Administrators Licensed in India as of 2006-07


Sl No TPAs
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Dawn Services Pvt. Ltd Parekh Health Management Pvt Ltd Medi Assist India Pvt. Ltd MD India Healthcare Services Pvt. Ltd Paramount Health Services Pvt Ltd E Meditek Solutions Ltd Heritage Health Services Pvt Ltd Universal Medi- Aid Services Ltd Focus Healthcare Pvt Ltd Medicare TPA Services Pvt Ltd Family Health Plan Ltd Raksha TPA Pvt Ltd TTK Healthcare Services Pvt Ltd Anyuta Medinet Healthcare Pvt Ltd Sl No 15 16 17 18 19 20 21 22 23 24 25 26 27 TPAs East West Assist Pvt Ltd Med Save Healthcare Genins India Ltd Alankit Healthcare Ltd Health India TPA Services Pvt Ltd Good Health Plan Ltd Vipul Med Corp. Pvt. Ltd Park Mediclaim Consultants Pvt. Ltd Safeway Mediclaim Services Anmol Medicare Ltd Dedicated Healthcare Services (India) Pvt. Ltd Grand Healthcare Services (India) Pvt. Ltd Rothshield Healthcare (TPA) Services Ltd

Source: Insurance Regulatory Authority of India; http://www.irdaindia.org;

3.1.4 Accreditation of Healthcare Service Providers Accreditation of healthcare service providers is a voluntary process by which an authorised agency or organisation evaluates and accredits health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes. Accreditation can thus be understood as an indicator of professional achievement and quality of care. Health services are increasingly coming under independent evaluation by accreditation agencies in many countries.

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India made an attempt to have a voluntary accreditation system since late 1980s when the Bureau of Indian Standards laid down standards for 30, 100 and 250 bed hospitals. In addition, the National Institute of Health and Family Welfare had specified rules for hospitals with more than 50-beds. Several state governments have also attempted to set standards, since health is a state subject. In order to have a united and single system to monitor the functioning of hospitals in India, an Inter-Ministerial Task Force was set-up in 1991; the recommendations of the Task Force led to the setting up of Quality Council of India (QCI) in 1997 as an autonomous body. Under the national accreditation structure of QCI, a National Accreditation Board for Hospitals and Healthcare Providers (NABH) has been set-up to establish and operate accreditation programme for healthcare service providers. The Board of NABH is having representation from stakeholders including government, consumers, and healthcare industry. NABH is an institutional member of International Society for Quality in Healthcare (ISQua). NABH standards for hospitals provide a framework for quality assurance and quality improvement in hospitals, focussing on patient safety and quality of care. The standards call for continuous monitoring of sentinel events and comprehensive corrective action plan leading to building of quality culture at all levels and across all the functions. The standards are equally applicable to hospitals and nursing homes in the government as well as in the private sector. NABH also has plans to draw up separate standards for Ayurvedic Centres in the country, in addition to formulating of standards for ambulance services, blood banks, dental centres and stand-alone clinics. Over 30 applications from various hospitals / healthcare centres have been received by NABH for accreditation. Few hospitals have been already granted accreditation by NABH. NABH estimates that about 250 hospitals in secondary / tertiary level will be able to comply with the NABH standards (Box 10) in the next couple of years.

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Box 10: Outline of NABH Standards

Access, Assessment and Continuity of Care Patient Rights and Education Care of Patient Management of Medication Hospital Infection Control Continuous Quality Improvement Responsibility of Management Facility Management and Safety Human Resources Management Information Management System
Source: National Accreditation Board for Hospitals and Healthcare Providers; http://www.qcin.org/html/nabh/nabh_stand.php

In addition, Indian hospitals are also increasingly turning to international accreditation agencies to standardise their protocols and project their international quality of healthcare delivery. As of October 31, 2007, there are eight hospitals in India accredited to JCI. These are given in Table 9. India is ninth largest country in the world with six JCI accredited hospitals. In addition, several Indian hospitals are in the process of getting accreditation. A comparison of countries with number of JCI accredited hospitals is given in Exhibit - 16. List of JCI accredited organisations in the world (as of December 31, 2007) is given at Annexure 2.

3.1.5 Accreditation of Clinical Laboratories Indian healthcare centers including stand-alone clinical laboratories are going for national and international accreditation. In India, National Accreditation Board for Laboratories (NABL) provides laboratory accreditation services in accordance with ISO 15189:2003 standards. NABL also satisfies the requirements of Asia Pacific Laboratory Accreditation Cooperation (APLAC) and International Laboratory Accreditation Cooperation (ILAC) mutual recognition agreements. Several pathological clinics in India have been accredited by NABL.
Some hospitals and stand-alone clinical laboratories are also going for international accreditation, especially from the College of
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Table 9: List of JCI Accredited Hospitals in India Sl. No Name and Place Accredited on
1 2 3 Indraprasta Apollo Hospital, New Delhi Wockhardt Hospital, Mumbai Apollo Hospitals, Chennai June 18, 2005 August 25, 2005 January 29, 2006 Disease- or ConditionSpecific Care (DCSC) Certification for Acute Stroke: 29 April 2006 February 18, 2006 April 28, 2006 October 20, 2006 February 3, 2007 June 15, 2007

4 5 6 7 8

Shroff Eye Hospital, Mumbai Apollo Hospitals, Hyderabad Asian Heart Institute, Mumbai Satguru Pratap Singh Apollo Hospital, Punjab Fortis Hospital, Mohali

Source: Joint Commission International; http://www.jointcommissioninternational.com/23218/iortiz/, 2007

Exhibit 16: Country-wise JCI Accredited Hospitals in the World

Source: Joint Commission International; http://www.jointcommissioninternational.com/23218/iortiz/,2007

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American Pathologists (CAP) Laboratory Accreditation (List given in Table 10). Such accreditation helps the hospitals / laboratories in achieving the highest standards of excellence in order to positively impact patient care.
Table 10: List of Indian Clinical Laboratories with CAP Laboratory Accreditation Sl. No Name and Place 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15 BAAP Diagnostics Ltd., Ahmedabad Clinigene Clinical Laboratory, Bangalore Dr. Lals Pathological Labs (P) Ltd., New Delhi Dr. Lals Pathological Labs (P) Ltd., Mehruali-Gurgaon Ehrlich Laboratory (P) Ltd., Chennai Igate Clinical Research International (P) Ltd., Mumbai Lambda Therapeutic Research Ltd., Ahmedabad Manipal Acunova Limited, Bangalore Manipal Acunova Limited, Manipal Metropolis Health Services (India) Ltd., Mumbai P D Hinduja National Hospital & Medical Research Reliance Clinical Research Services Ltd., Navi Mumbai SRL Ranbaxy Ltd., Mumbai Supratech Micropath Lab & Research Institute, Ahmedabad Thyrocare Technologies Limited, Navi Mumbai

Source: College of American Pathologists, USA; http://www.cap.org/apps/cap.portal?_nfpb=true&portlet

3.1.6 Traditional Healthcare Systems in India In India, in addition to existence of modern medicine, indigenous or traditional medical practitioners continue to practice throughout the country. Popular indigenous healthcare traditions include Ayurveda, Siddha, Unani, Homeopathy, Naturopathy, and Yoga.
The Ayurveda (meaning science of life) system deals with causes, symptoms, diagnoses, and treatment based on all aspects of well-being (mental, physical, and spiritual). These professionals,
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Box 11: About CAP Laboratory Accreditation Programme

The goal of the CAP Laboratory Accreditation Programme is to improve patient safety by advancing the quality of pathology and laboratory services through education, standard setting, and ensuring laboratories to meet the regulatory requirements. The CAP Laboratory Accreditation Programme meets the needs of a variety of laboratory settings from complex university medical centers to physician office laboratories. The programme also covers a complete array of disciplines and testing procedures. The comprehensive nature of CAP accreditation helps in achieving consistently high level of service throughout an institution or healthcare system. CAP Laboratory Accreditation Programme has recognition of the Centers for Medicare and Medicaid Services (CMS), USA and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), USA, and thus can be used to meet many certification requirements. There are over 6,000 laboratories worldwide that have met the standards of excellence required under CAP Laboratory Accreditation Programme.
Source: College of American Pathologists, USA. :http://www.cap.org/apps cap.portal?_nfpb=true&portlet_3_1_actionOverride

traditionally, have been inheriting the skills from their ancestors. However, with the advent of education, a variety of institutions offer training in indigenous medical practice. The Siddha system defines disease as the condition in which the normal equilibrium of the five elements in human beings is lost resulting in different forms of discomfort. The diagnostic methods in Siddha medical system are based more on the clinical acumen of the physician after observation of the patient, pulse and diagnosis and clinical history.

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Yoga is a science as well an art of healthy living physically, mentally, morally and spiritually. Yoga is believed to be founded by saints and sages of India several thousand years ago. Yoga has its origin in the Vedas, and its philosophy is an art and science of living in tune with the universe. Yogis gave rational interpretation of their experiences about Yoga and brought a practically sound and scientifically prepared method within every ones reach. Naturopathy has several references in the Vedas and other ancient texts, which indicate that these methods were widely practised in ancient India. Naturopathy believes that all the diseases arise due to accumulation of morbid matter in the body and if scope is given for its removal, it provides cure or relief. It also believes that the human body possesses inherent self-constructing and self-healing powers. Naturopathy differs slightly with other systems of medicine, as it does not believe in the specific cause of disease and its specific treatment but takes into account the totality of factors responsible for diseases such as ones un-natural habits in living, thinking, working, sleeping, or relaxation, and the environmental factors that disturbs the normal functioning of the body. Unani system of medicine believes that the body is made up of four basic elements viz., earth, air, water and fire, which have different temperaments i.e. cold, hot, wet and dry. After mixing and interaction of four elements a new compound having new temperament comes into existence i.e. hot-wet, hot-dry, cold-wet and cold-dry. The body has simple and compound organs, which got their nourishment through four humours, viz. blood, phlegm, yellow bile, black bile. Unani system of medicine believes in promotion of health, prevention of diseases and cure. All these traditional healthcare systems are attracting national and international patients, and generate tourism flows. In addition to such healthcare systems, there are also faith / spiritual healers, who are largely present in rural parts of India. Some spiritual leaders use one or more of the traditional therapies, viz, Ayurveda, Yoga or Naturopathy as one of the healing modes to cure their clients. Such spiritual leaders are attracting large gathering, especially international travelers from various countries.

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Both the Government of India and state governments have realized the potential of attracting tourism leveraging traditional wellness systems of India. Some state governments have been projecting their states as center for traditional wellness systems (e.g. Kerala as Ayurveda hub and UP as Yoga hub). Some state governments have announced tourism policy leveraging the potential of traditional healthcare systems. The attempts by the state Governments to attract tourists are not restricted to traditional medical systems, but also through leveraging spiritual tourism / faith healing. For example, Andhra Pradesh has drawn up an action plan to promote spiritual tourism, especially to attract German tourists, combining visits to famous temples along with Yoga, meditation and Vedanta. Similarly, Uttar Pradesh is promoting the state as Yoga hub, leveraging the presence of religious circuits and being a land of Sadhus.

3.1.7 Aromatherapy Aromatherapy is one of the holistic forms of treatment. It is a form of therapy using essential oils extracted from products of aromatic plants, shrubs and trees. Aromatherapy is used for treatment of both physical and psychological well-being of the patients. Aromatherapy has been practiced for a long time, with rising popularity, of-late. Scientific research continues in the efficacy of essential oils and associated aromatherapy into the physical and psychological well-being of an individual.
The objective of Aromatherapy is to treat the disease as a whole rather than the symptoms alone. The approach adopted by an Aroma therapist has the following benefits: It can help patients to assess their own lifestyles, their states of mind, and the mental and physical demands that influences their health; It enables the therapist to look more closely at the wellness of patient and identify the root causes of the symptoms of any disease; and It promotes a state of balance within mind and body, which will enable the individual to cope better with illness.

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Box 12: Ayurveda Indias Traditional Wellness System

The system of Ayurvedic medicine has evolved over thousands of years through a process of experience, observation, experimentation and intuition. Ayurveda provides a complete system of preventive medicine and healthcare, which has been proven as its effectiveness over a long period in India. The sages of the time, who were physicians and surgeons as well saw health as an integral part of spiritual life. The Vedic Brahmanas were not only priests performing religious rites and ceremonies but also physicians practicing Ayurveda (Vaidyas). It is said that thy received their training in Ayurveda through direct cognition during meditation. In other words, the knowledge of the use of various methods of healing, prevention, longevity and surgery came through Divine revelation. These revelations were transcribed from the oral tradition into book form, interspersed with the other aspects of life and spirituality. The science of Ayurveda is based on the knowledge of the human constitution. If every individual knows his or her own constitution, they can understand what constitutes a good diet and lifestyle for themselves. The five great elements, viz., ether, air, fire, water and earth are manifested into the three Doshas or biological organizations known as Vata, Pitta and Kapha. These biological organizations are used by an individual to gain a full understanding of all aspects of bodily functions, in order to establish the harmonious balance required for a healthy existence. In due course, Ayurveda, which started as a magico-religious practice, matured into a fully developed medical science with eight branches that have parallels in the western system of medicine. However, unlike modern medicine system, Ayurveda is based on natural herbs, which gives distinct advantage.
Source: Exporting Indian Healthcare; Export-Import Bank of India; Quest Publications; October 2002.

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Box 13: YOGA A Fitness System of Indian Origin

Yoga represents a process through which one can learn how to live in a most integrated way. The science of Yoga and its techniques have been reoriented to suit modern sociological needs and lifestyles. Today, there are hundreds of Yoga styles practiced; however, the popular styles include Bhathi Yoga, Karma Yoga, Gnana Yoga, Raja Yoga, Mantra Yoga, Laya Yoga, Tantra Yoga, Hatha Yoga, Kundilini Yoga and Kriya Yoga. Rishikesh is called the Yoga capital of the world. There are a large number of institutions and Yoga professionals in India. Since there is no recognized apex organisation, where the institutions have to register, the exact number cannot be stated, though it is estimated to run in to several thousands. In India, the awareness regarding Yoga and its applications is on the increase and today a lot of people are coming ahead and taking up Yoga courses. Advantage India India is in an advantageous position to tap the global opportunities in this sector. The tradition of Yoga was born in India several thousand years ago. Its founders were great saints and yogis. Yoga has its origins in Vedas, the oldest record of India culture. We have the history of expertise in imparting the Yoga training since the ancient time. The great Indian sage, Patanjali, systematized the Yoga practice in his Yoga Sutra. Although this work was followed by many other important texts on Yoga, his book is the most significant one as it has touched almost all aspects of human life. Most of the popular Yoga institutions in the world have their parent institutes or governing bodies in India, and thus placing India in an advantageous position to tap the global opportunities.
Source: Exim Research

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Box 14: Yoga and its Health Benefits

Yoga, the art and science of maintaining physical and mental well-being, has its origin in India. Yoga is one of the most ancient, yet vibrant, traditions that is getting increasingly popular today. A potent stress-buster, Yoga is an instrument to self evolvment and enlightenment, through physical and mental well-being. Broadly, Yoga, when performed with perseverance, precision, patience and shraddha, yield highly rewarding results. They promote health and consequently beauty. But to derive maximum benefit, one has to embark on this daily practice or rather pilgrimage, with passion and commitment. Yogasanas keep the spinal column supple, strong and healthy. This results in a steady erect posture, boosting self confidence. During Yogasanas, the alternate stretching and relaxation of muscles facilitates blood circulation and supply of oxygen, rejuvenating every cell of the body. Various Yogic postures gently massage internal vital organs, keeping them in perfect condition. Cholesterol levels are kept in check and the blood pressure is normalized. This internal harmony cleanses and detoxifies the body and boosts the immune system. Yogasanas make the body toned, strong and flexible. Standing asanas like the Tadasana and Trikonasana result in perfectly toned and shapely legs and ankles. Certain inverted postures - like the Sarvangasana results in free flow of blood to the neck, face and hair. Facial skin becomes taut and wrinkle free, attaining a radiant glow. The hair becomes thick and glossy, and the eyes acquire a natural shine. Yogasanas speed up metabolism, resulting in a slim figure. There is no accumulation of fat anywhere in the body. Forward-bending exercises result in flab-free abdomen. This natural pampering of the body by Yogasanas result in slowing down of the ageing process, both physical and mental. This in turn leads to positivism in our thoughts, actions and relationships.
Source: Geetika Jain, www.spirituality.indiatimes.com/articleshow/ 2376027.cms

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Box 15: Spiritual / Faith Healing in India

Spiritual / faith healing is defined by different people differently. In the context of our study, we may define spiritual / faith healing as a mode to achieve wellness of a person. The principle behind any spiritual healing is to instigate an increase in the subtle basic sattva component in the person along with a concomitant decrease in the subtle basic tama component38. Thus, spiritual healing is about diagnosis and removal of the spiritual root cause of a physical or mental problem. This could be done either through self-healing or through the help of spiritual healers. India is being perceived as the land of diverse cultures and beliefs with inherent spirituality. Many travelers / writers who have visited India from abroad, since many centuries, have scripted about many legendary worship sites and pilgrim centers which are meant for wellness and healing. Many domestic travelers have traveled scouting for inner-peace to various places, be it religious centers or persons who perform faith healing. India has many lavishly built religious monuments that are famous in attracting national and international travelers. To name a few, religious places like Amritsar, Dwaraka, Ajmer, Vaishno Devi and Tirupathi have been serving as spiritual as well as tourism centers. Some people visit some of the spiritual centers such as Gunaseelam and Chotanikkara, seeking mental healing. India is also having motivating speakers and proponents of spirituality like Swami Baba Ramdev, Sri Sri Ravishankar, Mata Amritanandmayi, who are attracting large number of, both national and international, tourists. Such spiritual leaders promote brand India as Yog-Bhoomi through discourses, seminars and other outreaching measures. While the number of persons visiting spiritual centers or spiritual leaders for healing is increasing, it is yet to be proven scientifically the efficacy of spiritual healing.
Source: Exim Research
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Spiritual Science Research Foundation; www.spiritualresearchfoundation.org;

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The main method adopted in aromatherapy is through massage with the application of essential oils. While the whole body is provided with massage using suitable essential / herbal oils, greater attention is provided to specific areas to derive extra benefit for a given problem. Aromatherapy also plays an important role during pregnancy helping the mother-to-be to cope with the pregnancy related problems, especially for the pain relief and relaxation. However, experts suggest that some essential oils are to be completely avoided during pregnancy due to diverse reasons, as some of them are considered as abortifacients. Aromatherapy is also used on babies for the benefit of relaxation and skin development. However, experts opine that not all essential oils are to be used on babies, but with either almond oil or olive oil. Wider variety of oil may be used on children once they grow up. Aromatherapy has been used in Vedic India. Floral and other herbal essences have been in continuous use by the Indian indigenous medical systems, such as Ayurveda, for a very long period. Ayurveda embraced herbs and aromatics as an important part of the philosophy of healing, using fresh herbs, dried herbs such as tea, or herbs compounded into powder and often hand rolled into pills using fresh plant juices. In Ayurvedic massages, herbal essences are used to provide mental and physical wellbeing of the individuals. India has rich bio-diversity and is housed with large number of medicinal plants and spices. India is the largest producer, consumer and exporter of spices, with a 45 per cent share by volume and 23 per cent share by value, in the world market. The Indian spice export basket consists of around 50 spices in whole form and more than 80 products in value added form. India is second largest exporter of medicinal plants in the world. Most of the medicinal plants and spices grown in India have aromatic characteristic. These medicinal plants and spices are still valued in international markets for their aromatic properties. Some of the spices produced in India and their important flavour compounds are given in Table - 11. India is also playing significant role in the production and processing of essential oils. Indias rich bio-diversity, coupled with
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competent scientific force, and favourable processing conditions make the country as the natural choice to become a foremost leader in aroma business. Some of the culinary effects of essential oils are: Angelica essential oil used to treat digestive and respiratory ailments; Bay laurel oil used to treat problems associated with the luymphatic system; Basil oil strengthens and supports nervous system Bergamot oil relieves depression and has calming properties Pepper oil improves digestion and stimulates circulation

3.2 INTERNATIONAL TOURISM IN INDIA


Tourism is one of the important components in the Indias services sector, which has exhibited considerable dynamism in recent years. Tourism in India contributes to around 6.11% of GDP, as compared to over 10% of GDP generated in the world. The sector generates employment for over 40 million persons, a share of nearly 9% of total employment generated in the country. Share of India in world international tourist arrivals has been growing at a moderate level; from a level of 0.39% in 1995, Indias share has gone to 0.52% in 2006 (Table 12). In terms of absolute numbers, India received 4.40 million international tourists in 2006. Foreign exchange generated through the arrival of international tourists in India amounted to an equivalent of over Rs. 30,000 crores. It may be mentioned that foreign exchange earnings by India has been growing greater than the growth in tourist arrivals. The trend in international tourist arrivals and foreign exchange earnings in India is depicted in Exhibit 17. Another important feature of international tourism in India is the foreign exchange earnings per international tourist arrived in India. Foreign exchange earning per international tourist arrived in India is over US $ 2000 as compared to the world average of US $ 873 in 2006 (Exhibit 18). This is higher than many other competitor countries in the region such as China (683), Sri Lanka (984), Malaysia (548), Thailand (892), Singapore (934), and
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Table 11: Important Flavour Compounds of Select Spices Spice Important Flavour Compounds
Allspice Anise Black pepper Caraway Cardamom Cinnamon, cassia Chilli Clove Coriander Cumin Dill Fennel Ginger Mace Mustard Nutmeg Parsley Saffron Turmeric Vanilla Basil, Sweet Bay laurel Marjoram Oregano Origanum Rosemary Sage, Clary Sage, Dalmation Sage, Spanish Savory Tarragon Thyme Peppermint Spear mint Eugenol, <-caryophyllene (E)-anethole, methyl chavicol Piperine,S-3-Carene, -caryophyllene d-carvone,carone derivatives a-terpinyl acetate, 1-8-cineole, linalool Cinnamaldehyde,eugenol Capsaicin,dihydro capsaicin Eugenol, eugeneyl acetate d-linalool, C10-C14-2-alkenals Cuminaldehyde, p-l,3-mentha-dienal d-carvon (E)-anethole, fenchone Gingerol,Shogaol, neral,geranial a-pinene,sabinene, 1-terpenin-4-ol. Ally isothiocynate Sabinine,a-pinene, myristicin Apiol Safranol Turmerone,Zingeberene, 1,8-cineole Vanillin, p-OH-benzyl-methyl ether Methylchavicol,linalool, methyl eugenol 1,8-cineole e- and t-sabinene hydrates, terpinen-4-ol Carvacrol,thymol Thymol, carvacrol Verbenone,1-8-cineole, camphor, linanool Salvial-4(14)-en-l-one, linalool Thujone,1,8-cineole, camphor e- and t-sabinylacetate, 1,8-cineole, camphor Carvacrol Methyl chavicol,anethole Thymol, carvacrol 1-menthol, menthone,menthfuran 1-carvone,carvone derivatives

Source: Spices Board, Government of India; www.indianspices.com;

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Exhibit 17: Trends in International Tourist Arrivals and Foreign Exchange Earnings in India

Source: World Tourism Organisation; India Tourism in 2005, Incredible India, Ministry of Tourism, Government of India, August 2006.

Table 12: International Tourist Arrivals in World vis--vis (Million Year International Tourist International Tourist Arrivals in the World Arrivals in India 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 544.9 575.3 597.8 617.4 641.1 685.5 683.8 702.8 690.9 766.0 808.0 842.0 2.12 2.29 2.37 2.36 2.48 2.65 2.54 2.38 2.73 3.46 3.92 4.40

India Persons) Share of India (%) 0.39 0.38 0.38 0.38 0.38 0.39 0.37 0.34 0.39 0.45 0.49 0.52

Source: World Tourism Organisation; India Tourism in 2005, Incredible India Ministry of Tourism, Government of India, August 2006.

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Indonesia (897). Such high spent in India may be attributed to more number of days spent by a foreign tourist in India compared to other countries besides the visit of high-end tourist to India. According to a foreign tourist survey conducted by Ministry of Tourism (MOT), Government of India, a foreign tourist from the top 15 international markets for India spend in the range of 7 to 18 days in India, the overall average being 16 days. Nearly two-third of international tourist arrivals in India are catered by UK and USA (Exhibit 19). Other major source markets for India include Canada, France, Sri Lanka, Germany, Japan, Malaysia, Australia and Singapore. These ten countries cumulatively account for around 57% of international tourist arrivals in India. Nearly 50% of international tourists have stayed in budget hotels, as compared to 20% that have stayed in starred hotels. Nearly 50% of tourists are repeat visitors; about 10% of total international visitors to India have visited more than five times39.
Exhibit 18: Per Tourist Foreign Exchange Earnings by India and Select Countries (2006)

Source: India Tourism in 2005, Incredible India, Ministry of Tourism, Government of India, August 2006.

39 International Passenger Survey - 2003; Incredible India, Ministry of Tourism, February 2006, New Delhi.

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Exhibit 19: International Tourist Arrivals by Countries - 2006

Source: Tourism Statistics 2006 at a Glance, Incredible India, Ministry of Tourism, Government of India, September 2006, New Delhi.

3.2.1 Tourism Promotion in India The Approach Paper 40 to the Eleventh Five Year Plan has highlighted the importance of tourism sector in terms of its contribution to GDP and employment generation, and proposed to focus on creation of adequate tourism infrastructure like modernisation and expansion of airports, increase in accommodation facilities under star and budget category and improved road connectivity to tourist destinations. In addition, the Approach Paper has sought to ensure the upkeep and preservation of historical sites and other tourist places, as one of the strategies to attract international tourists. Other strategies proposed by the Approach Paper include enhancing Indias competitiveness through reduction in various taxes, provision of hassle-free inter-state movement of passenger vehicles, and conduction of skill development programmes in hotel and catering management streams.
Towards Faster and More Inclusive Growth, An Approach to the 11th Five Year Plan (2007-2012, Planning Commission, Government of India, December 2006.
40

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A National Policy on Tourism highlighting the importance of the sector in economic development of India was announced in 1982. The policy was formulated at a time much before the economic reforms in India. Thus the policy did not emphasize much on the role of private sector and foreign investment. With the objective of providing thrust on private sector partnership in tourism development, the Ministry of Tourism, Government of India has announced a New National Tourism Policy, in 2002. The key areas identified to provide the requisite thrust to the tourism industry include Swagat welcome; Soochana information; Suvidha facilitation; Suraksha safety; Sahyog coopration; Samrachana infrastructure development; and Safai cleanliness.

3.2.2 Exclusiveness of India in Tourism41 India has many tourist attractions that have healing abilities and are capable of providing rewarding experiences of life. India has the Himalayan ranges in the north, a long coastline surrounded by seas in the south. In addition, India is rich in varied landscapes, enchanting historical sites and royal cities, clean beaches, serene mountain retreats, rich cultures and festivities to enjoy and rejuvenate.
In any part of the year, India can offer a wide selection of destinations and experiences. In summer, there are lovely retreats amidst the heady beauty in the Himalayas or the lush-heights of the western Ghats with cool trekking trails, tall peaks, or stretches of white water for the adventure seekers. In the cool Indian winter, cities come alive with cultural feasts of music and dance. The sun-clad beaches are ideal locations for rejuvenation in the winter. The wild-life sanctuaries with their abundance of flora and fauna provide delights to the mind and rejuvenation to the body. Various tourism themes are being promoted in India, which are described below:

41

This section is written using information from literature / publications / promotional materials of the Department of Tourism, Government of India.

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Adventure Tourism: The country offers a wide range of adventure sports for tourists. Trekking and skiing in the Himalayas; white water rafting on the rivers such as Ganges and Beas; camel and jeep safaris in the deserts of Rajasthan, paragliding in Himachal Pradesh, water-sports in Goa; Scuba diving in Andaman and Lakshadweep islands are some of the options available to adventure seeking tourists. Lakshadweep islands also offer excellent wind surfing and snorkelling in the crystal clear waters of the lagoons. Sun and Sand Coastal Tourism: Indias coastal states such as Gujarat, Masharashtra, Goa, Karnataka, Kerala, Tamil Nadu, Andhra Pradesh, West Bengal and Orissa have a choice of beaches. Many breathtaking beaches promise perfect escape to tranquility. While some of them are for quite beaches (like Chorwad, Ahmedpur and Mandvi in Gujarat; Gopalpur in Orissa), the beaches in Goa are popular for wind-surfing and yatching. The Backwaters: Kerala is said to have sprung from the ocean. All along the coast, these exotic backwaters, canals, lagoons and inlets create an intricate maze that stretches for 1900 km. across the land. The serene villages in the backwaters of Kerala are living portrait of Keralas rural life. Eco-Tourism: The Himalayan Range spread across five Indian states providing widest monotonic geographical variety. Wide sweeping valleys and deep gorges give way to thick deciduous forests and alpine meadows, undulating tea gardens and slopes, bar narrow terraces, gently contoured hills, snow draped peaks surrounded by a fluff of clouds, thundering rivers and deeply fissured glaciers provide excellent locations for eco-tourism. In the southern part of India, the south and eastern Ghats, especially the Nilgiri Ranges, have its own unique appeal to eco-tourism. Architectural Treasures: India has rich architecture traditions, which have the beginning as old as 3rd millennium BC. Indian architectural tradition is the living vital art of the various dynasties, which ruled over it. The Buddhist stupas (dates back to 230-500 AD); Jains sculpture at ancient Palitana, Ajanta, Ellora, and Mount Abu; the Hindu temples with profuse carvings and Gopurams of the South India; arches and domes, filigrees in architecture promoted by Mughals; presidency towns built by modern rulers like British, French, Portuguese, are some of the vital arts
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assimilating the influence of various dynasties that ruled over the country. Forts and Palaces: Indias once famous princely kingdoms, which carried feudal traditions, have built forts and palaces, some of which have been converted into hotels now. Jaipur, Jodhpur, Jaisalmer, Bikaner in the state of Rajasthan; Mysore in Karnataka; Mughals forts in Northern India are some of the examples of several fascinating forts and palaces. Hill Delights: A journey through the hill resorts of India promises a deep and refreshing communion with nature in its varying beauty. Lush river valleys surrounded by snow-caped peaks, fruit-laiden orchards, gurgling streams and dense forests evoke enchantment and delights of hilly regions. The misty dawn on mountains creating magnificent landscapes extend to the entire north-eastern states, whose natural beauty has earned the title seven sisters. Other hill states, Himachal Pradesh and Jammu & Kashmir provides a breathtaking variety of the Himalayan splendour. The Nilgiris in the South have the picturesque Anantagiri, Udhagamandalam, Madikeri and Munnar. Mount Abu in Rajasthan, Panchgani in Madhya Pradesh and Mahabaleshwar in Maharashtra are other hill regions with tourist attractions. The Deserts: The state of Rajasthan has the mystique of the desert with sand dunes closer to the splendid cities of Jodhpur, Bikaner and Jaisalmer. The royal edifices take the tourists to the magnificence of the bygone era. Turbaned men with proud moustaches, and village girls in colourful attires and heavy jewellery swaying in the desert sands to match with the enchanting rhythm and melodies, are other attractions of the deserts of India. The Jungle: India is a land of wildlife providing delight for the natural lovers. Total area of Indias protected wildness is approximately 140,000 sq. km. and constitutes 4 percent of the centurys total land area. The country has preserved vast tracts of forests and habitats in its nearly 100 national parks over 400 wildlife sanctuaries. Indias climatic and geographic diversity makes it the home of over 350 mammals and 1200 bird species, many of which are unique to the sub-continent.

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The wildlife parks and sanctuaries, filled with varieties of tigers and elephants, the peacocks and the rhinoceros, are fascinating diversity of terrain, flora and fauna. In northern India, Corbett National Park and Dudhwa National Park in Uttar Pradesh, Kanha National Park and Bandhavgarh National Park in Madhya Pradesh and Rajasthans Ranthambore National Park and Sariska Tiger Reserve, are all the home of the magnificent predator-the tiger. These also have varieties of deers, and a range of lesser cats, mammals and birds. Island attractions:The Andaman and Nicobar, and Lakshadweep islands are enriched with white and sandy beaches, crystal-clear water and picturesque coral reefs. Sun-bathing in these islands along with snorkelling and scuba-diving are tourist attractions. Pilgrimage: India holds attractions, for pilgrim tourists of diverse religions, where religion is considered more than the act of worship, but a way of life. For the Hindus age-old cities of worship like Prayag (that provide holy confluence of Ganga, Yamuna and Saraswati rivers); Puri (Jagannath temple); Konark (Sun temple); Kanchipuram, Madurai, Tiruchirappalli and Kanniyakumari (Southern Gopurams), provide peace and reverence. In addition, there are also religious places that are carved with craftsmanship, at Belur and Halebid. In these temples, the interior and exterior walls are decorated with intricately-carved deities stylized motifs from nature and friezes depicting the life in the reign of the Hoysalas. There are also worship places for the Muslims (Delhi - Jumma Masjid), Christians (Churches in Goa and Kerala), Buddhists (Bodhgaya, Saranath, Kushinagar), Sikhs (Golden Temple) and Jains (Sravanabelagola), that have tourist attractions. North-East Region: Life moves at a serene pace in the northeastern region of India with the seven sister states are generously blessed with the natural beauty. The region is enriched with magnificent landscapes naturally created by verdant valleys, emerald tea gardens, lush forests and tumultuous rivers. A mistydawn of the mountains, bronze sun-set across the expanse of the Brahmaputra, and the clang of prayer bells at monasteries, provide healing to mental and physical well-being of the visiting tourists.
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3.2.3 Select Schemes for Tourism Development in India MOT, Government of India has set out several schemes supporting the tourism development initiatives of the state governments and private corporate sector. The focus of such schemes is to improve the existing products and developing new tourism products to match with other countries. These include: 3.2.3.1 Scheme For Product / Infrastructure And Destination Development For infrastructure and product development, MOT, Government of India, has been providing Central Financial Assistance to the State Governments with the objective of strengthening the infrastructure and product development all over the country. The destinations for support are identified, in consultation with state Governments, based on tourism potential, under an overall Master Plan, with forward and backward linkages, so as to develop them in an integrated manner.
Eligible activities include: improvement of the surroundings of the destinations, illumination, improvement of solid waste management systems and sewerage management, construction of budget accommodation, procurement of equipments related to tourism, signage, tourist centers and refurbishing the monuments. Eligible activities will be fully funded by the MOT. However, the state Governments will have the responsibility of making the land available, implementation of rehabilitation package, provision of external infrastructure (such as roads, power, water supply), maintenance and management of assets.

3.2.3.2 Scheme for Integrated Development of Tourist Circuits MOT has been extending assistance to state Governments for development of tourism circuits in order to identify and develop tourist circuits to match with international standards. Tourism circuits are identified in consultation with state Governments, as also the mode and channelisation of funds. DOT would bear 100% of total capital cost of the project.

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Box 16: New National Tourism Policy (2002)

Broadly, the National Tourism Policy (2002) attempts to: Position tourism as a major engine of economic growth; Harness the direct and multiplier effects of tourism for employment generation, economic development and providing impetus to rural tourism; Focus on domestic tourism as a major driver of tourism growth; Position India as a global brand to take advantage of the burgeoning global travel trade and the vast untapped potential of India as a destination; Acknowledges the critical role of private sector with government working as a pro-active facilitator and catalyst; Create and develop integrated tourism circuits based on Indias unique civilization, heritage and culture in partnership with states, private sector and agencies; Ensure that the tourist to India gets physically invigorated, mentally rejuvenated, culturally enriched, spiritually elevated and feel India from within. To achieve the overall vision for the development of tourism, five key strategic objectives need to be achieved. They are: Positioning and maintaining tourism development as a national priority activity; Enhancing and maintaining the competitiveness of India as a tourism destination; Improving Indias existing tourism products and expanding these to meet new market requirements; Creation of world class infrastructure; Developing sustained and effective marketing plans and programmes.
Source: National Tourism Policy 2002, Ministry of Tourism, Government of India, New Delhi

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3.2.3.3 Scheme of Assistance for Large Revenue Generating Projects The Government, recognizing the role of private corporate sector in development of tourism infrastructure in India, supports large revenue generating projects, under public-private partnership. Large projects like Tourist trains, Cruise vessels, Cruise Terminals, Convention Centres and Golf Courses would qualify for such assistance. A SPV would have to be set up by the implementing private agency prior to the consideration of their project under this scheme. The amount of assistance would be released to SPV through the financial institutions. The quantum of subsidy for the projects will normally be determined through a competitive bidding process, with a cap of Rs. 50 crores subject to a maximum of 25% of total project cost or 50% of equity contribution of the private promoter, whichever is lower. 3.2.3.4 Scheme for Capacity Building for Service Providers Assistance under this scheme is extended to eligible implementing agencies to undertake training programmes for select tourism service providers such as staff of bus / railway air stations, police personnel, immigration staff, taxi / coach drivers, staff at monuments, who come in contact with the tourists. The objective is to increase the skill-sets (of service providers), such as etiquette, behavioural and client handling manners, and communication. In addition, the programmes may also cover areas such as personal hygiene, cleanliness, basic service techniques, garbage disposal and administering first aid. 3.2.3.5 Scheme for Rural Tourism Under this Scheme, thrust is to promote village tourism as the primary tourism product to spread tourism and its socio-economic benefits to rural and its new geographic regions. Key geographic regions are identified for development and promotion of rural tourism. The implementation is done through a Convergence Committee headed by the District Collector. Activities like improving the environment, hygiene and infrastructure are covered for assistance. Apart from providing financial assistance, the focus is to tap the resources available under different schemes of Department of Rural Development, Government of India, state

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Governments and other relevant departments of the Government of India.

3.2.3.6 Scheme for Organising Tourism Related Events Under this scheme, MOT provides financial assistance to state governments for organizing events such as fair, festival, show, seminar, conclave and convention for promotion of domestic and international tourism. 3.2.3.7 Scheme for IT Initiatives Under this scheme, state tourism departments are encouraged to implement Information Technology (IT) initiatives for improved tourist information, facilitation, marketing and publicising of tourist products. Assistance is given up to 50% of IT project cost, such as purchase of hardware / software, and production of CD / VCD or websites, subject to a defined ceiling. 3.2.3.8 Scheme for Market Development Assistance MOT is also administering a Market Development Assistance (MDA) scheme, which provides financial support to approved tourism service providers (such as hoteliers, travel agents, tour operators, tourist transport operators, whose turnover include foreign exchange also), for undertaking activities such as sales cum - study tour, participation in fairs and exhibitions, and publicity through printed material.

3.3 HEALTHCARE TOURISM IN INDIA


India holds competitive advantages in healthcare tourism be it the low-cost advantage, availability of healthcare professionals, reputation for treatment in advanced healthcare segments such as cardio-vascular surgery, organ transplants, and eye surgery, increasing popularity of Indias traditional wellness systems, and strengths in information technology. The International Passenger Survey (2003) conducted by the Ministry of Tourism, Government of India estimates that about 2.2% of foreign travelers visited India with the objective of healthcare and treatment (Exhibit 20). The same share, if extrapolated to the foreign tourist arrival statistics for the year 2006 (estimated to

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Exhibit 20: Purpose of Visit

Source: International Passenger Survey, 2003, Incredible India, Department of Tourism, Government of India, February 2006, New Delhi.

be 4.4 million), would give an estimated number of about 97,000 foreigners visiting India with healthcare objectives. Further, the International Passenger Survey 2003 has estimated that about 2 million non-resident Indians visiting India every year, of which about 10% come with healthcare objective. This works out to about 200,000 NRI patients visiting India to undergo various treatments. All these put together, the visitors to India with healthcare objective could be estimated at around 300,000 patients. In addition, there are a large number of international visitors, including non-resident Indians, who come for other purposes, but use wellness systems, such as Ayurveda / Yoga or Spiritual Healing. Even if we assume that only 5% of foreign travelers undertake such wellness systems in India, the estimated number of travelers under this category would be 200,000. Thus, it may be quantified that the healthcare visitors to India would easily be in the range of around 500,000. Based on the data on international tourist arrivals and foreign exchange earned by India42, it could be estimated that average spending of international tourists visiting India was of the order of US $ 2000 per person. Using this data, the estimated total
42

India Tourism in 2005, Incredible India, August 2006;

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expenditure incurred by foreign healthcare tourists works out to about US $ 200 million. The International Passenger Survey 2003, of Ministry of Tourism, Government of India estimates an average per capita expenditure of Rs. 48,000 for NRIs visiting India. For the 200,000 estimated NRIs visiting India, annually, with healthcare objective, the total expenditure works out to approximately US $ 240 million. In addition, we may assume that 10% of the general foreign visitors may use wellness systems during their travel to India, and spend about 20% of their total expenditure on healthcare; the total spending on healthcare by these travelers works out to approximately US $ 150 million. Putting together, the healthcare tourism industry in India generated revenue of over US $ 600 million (or about Rs 2400 crores) in 2006. It may be mentioned that the given estimate is considering healthcare in its broader perspective.

3.3.1 Healthcare Tourism Initiatives in India The tourist inflow for a wide healthcare service spectrum, from wellness tourism to surgery and rehabilitation has made all interested stakeholders to tap the unexplored potential. Both the industry and Government (central and state governments) are independently or jointly taking initiatives to project India as an ideal healthcare destination. 3.3.2 Industry Initiatives Healthcare centers are establishing world-class infrastructure (both medical as well as patient-handling infrastructure) in order to attract international patients. The hospitals are also constantly upgrading technology by acquiring state-of-the-art equipments. The players are setting up comprehensive diagnostic centres, imaging centers and world-class blood banks.
Some hospitals have established special wards for international patients as also special desks to handle international patients. Such special desk will have officials to handle translation, travel requirements and food and beverages needs. Some hospitals are also tying up with travel / tour operators to offer healthcare tourism as a single service package.

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Some hospitals project themselves operating in specialty fields, such as cardiology, ophthalmology, dentistry. Some of them have even set up specialty centers focusing on areas such as transplantation surgery. Few hospitals are organizing international conferences in such specialties, and invite medical fraternities from various countries with the objective of showcasing Indian skills in various healthcare segments. Such conferences also facilitate interactions with specialists and help enhance knowledge transfers. Few hospitals have established international collaborations both with developed and developing countries. Such collaborations are with hospitals, healthcare institutions, Government departments of health and family welfare, which would facilitate participation in healthcare delivery, treatment of their patients, and training of their medical / paramedical professionals. Such tie-ups have facilitated flow of patients from select countries to Indian hospitals, the treatment of which would be covered under the respective countrys national health programmes. Few hospitals are in the process of continuous innovation of products, services and facilities in order to give better value to the customers as also to stand ahead in the competition. While doing so, some hospitals are focussing on cost-effective-customer oriented technology. Quality, standardisation and accreditation are associated strategies followed by some Indian players. Indian healthcare institutions are increasingly going for international accreditation of hospitals and clinical laboratories. Indian healthcare establishments are also adopting marketing and promotional strategies. These are through participation in international trade fairs / exhibitions, international medical symposia / conferences. Internet is being used as an effective media of communication with international healthcare travelers. The healthcare industry in India has formed the Indian Healthcare Federation (IHCF) with the objective of collectively promoting healthcare industry in the country. A ten point agenda outlined by the Indian Healthcare Federation in order to impart quality, accessibility and affordability of healthcare in India is given at Annexure 3.

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Box 17: Indian Healthcare Federation

Indian Healthcare Federation (IHCF) is an independent nonstatutory body, with a membership of around 300 members, comprising non-government hospitals, diagnostic centers, medical equipment manufacturers and pharmaceutical firms. The main objective of IHCF is to promote and encourage healthcare industry in the country. IHCF seeks to function as a liaisoning medium between Government, health providers, medical equipment manufacturers and other medical institutions. IHCF also provides a common platform for its members to discuss and arrive at solutions for various issues related to healthcare industry and ensure organized action wherever necessary. IHCF endeavours for a diseasefree India by providing accessible quality healthcare every single citizen at affordable cost and transform India into a healthy and vivacious nation.
Source: Indian Healthcare Federation; www.indianhealthcarefederation.org;

The concept of telemedicine is also being promoted by Indian corporates while providing healthcare services. Some hospitals use the concept of telemedicine to undertake their social obligations of supporting Rural Health Mission of the Government, and some of them use the concept to provide distance consulting and treatment advise to the patients abroad.

3.3.3 Government Initiatives The Ministries of Health and Family Welfare, and Tourism, Government of India are evolving an approach to give a strategic push to open the Indian healthcare sector to foreign tourists. The Ministry of Health and Family Welfare has set up a National Accreditation Board for Hospitals, under the Quality Council of India for accreditation of hospitals. The policies adopted by other countries for accreditation of their hospitals are also being examined to gain from their experiences in taking this forward in India. Government of India has also taken the initiative of
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Box 18: Concept of Telemedicine

The World Health Organization defines Telemedicine as, The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities. The concept of telemedicine would thus include: Telehealth - use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education and training, public health and health administration; Teleconsultation - use of information and communications technology to enable clinical consultation between geographically separated individuals such as health care professionals and their patients; Telemonitoring - A real time and live interactive monitoring (evaluation) of technique(s) or procedure(s) of an applicant seeking procedures, or a surgeon seeking to certify or document his competence in a specific technique or procedure(s); Teletreatment advice provided to the patient through another doctor using information and communications technology about the course of treatment to be taken; Telediagnostics - is the use of information and communications technologies to enable the diagnosis of a patient between geographically separated individuals.
Source: Recommended Guidelines & Standards for Practice of Telemedicine, Report of the Technical Working Group for Telemedicine Standardisation, Ministry of Communications and Information Technology, Government of India, May 2003.

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rationalizing the flow of tourist traffic. Earlier, foreigners coming to India with healthcare objective were being granted tourist visa by Indian Missions abroad. As tourist visa is non-convertible, nonextendable and valid only for a period of six months, the healthcare patients and their accompanying persons faced difficulties in emergencies. To resolve this, Government of India has introduced a new category of visa - Medical Visa, which can be given for specific purpose of medical treatment to foreign tourists coming to India. Further, the Government has facilitated with a fast track clearance for the healthcare visitors at the airport. The Ministry of Communications and Information Technology, Government of India has developed a framework for IT Infrastructure for Healthcare (ITIH) prescribing appropriate standards for each stakeholder to build an integrated healthcare information network for India. This initiative is expected to bring in value and benefits to all healthcare players as also the users. At the state level, some state Governments are participating in healthcare tourism expos abroad. Such activities are being used as a platform to meet international experts from the medical fraternity and brief them about the competence of Indian healthcare industry in general, and the healthcare sector in the state, in particular. Further, at the state level, several initiatives are taken by the industry in association with the state governments. Kerala has made concerted efforts to promote healthcare tourism, leveraging Ayurveda, in a big way, which has resulted in a substantial increase of visitor arrivals into the state. Kerala Tourism Development Corporation (KTDC), since early 1990s has been promoting Ayurveda under the banner of healthcare tourism, and has started Ayurvedic health centers in its hotels. KTDC has also tied up with reputed Ayurveda centers in order to provide authentic treatment to the international travelers to Kerala. The Department of Tourism, Government of Kerala has classified the Ayurvedic centers in two categories - Green Leaf and Olive Leaf a sort of accreditation or grading of centres. With such initiatives, Kerala and Ayurveda have virtually become synonymous with each other. The current trends show that Kerala is emerging as a modern healthcare provider with significant collaborations of
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entrepreneurs in the private healthcare sector and the tourism industry. In Karnataka, the state is in the process of setting up of a Bangalore International Health City Corporation, which will offer patients a wide variety of health care products and treatments. The Government of Karnataka is also in the process of leveraging the states IT prowess to tap business in the healthcare outsourcing services. Leveraging IT skills would help enhance Karnatakas position in associated services to the growing healthcare sector such as medical billing, disease coding, forms processing and claims settlement. Karnataka is also bidding high on Telemedicine, a concept by which patients can be treated even when the doctor is geographically placed in another area. In Maharashtra, the Infrastructure Development and Support Act (MIDAS) of Maharashtra has granted the tourism activity with an industry status, with the objective of granting all the benefits and incentives that are given to other industries. This Act would also empower the Maharashtra Tourism Development Council (MTDC) as a Special Planning Authority, to procure and provide land available at various tourism estates without needing approval from the Maharashtra Industrial Development Corporation (MIDC). In Maharashtra, the industry in association with the State Government has set up Medical Tourism Council of Maharashtra. Gujarat is one of the few states in India to announce a separate policy for medical tourism, with the objective of creating integrated medical tourism circuits based on the location of specialty hospitals, heritage and culture. In addition, Gujarat is in the process of setting up a Healthcare Tourism Council in association with the healthcare and tourism industry. Goa, which has been for long attracting tourists for its beaches and exotic cuisine, has fine-tuned the hospitality skills into an art, and is now attracting healthcare tourists with focus on cosmetic treatments.

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Healthcare Tourism In India

Box 19: Medical Visa in India

Medical visas are issued by the Indian Missions / Posts abroad after scrutinizing the medical documents carefully and after satisfying the bonafide purpose for which the visa under medical conditions are sought. The visa officials may also satisfy themselves that the applicant has sought preliminary medical advice from his country of origin / country of residence and he has been advised to go for specialized medical treatment. The illustrative list of ailments that may be considered primarily would include neuro-surgery, ophthalmic disorders, heart related problems, reneal disorders, organ transplantations, plastic surgery and joint replacement. Medical visa is being granted if the treatment is to be undertaken in reputed / recognized specialty hospitals / treatment centers in India. In case the foreign national desires to undergo treatment under the Indian Systems of Medicine, such cases may also be considered. The initial period for issue of such visa may be upto a period of one year or the period of treatment, whichever is less, which can be extended for a further period of another year, upon the recommendation of the state Governments / Foreigners Regional Registration Office (FRRO), supported by relevant medical documents. Such visa will be valid for a maximum of three entries in one year. Foreigners coming on medical visas is mandatorily required to get registered themselves within a period of 14 days of arrival with the concerned FRROs. Attendant / family members of the patient coming to India for medical treatment are also granted visa under miscellaneous category that would co-terminus with the medical visa of the patient. Such visa is being granted to the spouse / children or those who have close blood relations with the patient, but not more than two persons. Such visitors are also required to get themselves registered with the local FRROs.
Source: Ministry of Tourism, Government of India; http:// www.incredibleindia.org/pdf/MedicalVisa.pdf

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