Introduction

Catalysed by emerging technologies, varying economic and demographic trends and a new age of healthcare consumerism; the worldwide scenario of healthcare is rapidly evolving. Additionally, a growing ageing population, and a swelling burden of diseases is rising the demand and cost of medical services. This evolution in healthcare is driving cross-country and cross-industry convergence (Deloitte Global, 2021), resulting in an upsurge in the worldwide medical tourism market. As this trend towards the healthcare is enduring around the world, more and more countries are extending their health systems to access care, not just for their natives but also gaining strength as leading service providers for international patients. While much of the initial focus was on the developed world, the epicentre is now shifting towards the emerging countries. Governments of these developing countries are working towards prioritising their health systems; enhancing productivity, boosting avenues for innovation and entrepreneurship, generating employment opportunities, increasing foreign exchange earnings, and hence driving GDP growth (Rahman, 2019).

India has been having its own unprecedented progress in this sector. To counter the emergent health issues, the health system in India has metamorphosed rapidly since the 90 s and has become the focal point of development. With the presence of clinical and technical expertise, international standards and highly competitive prices; India has emerged as a leading contender in the medical tourism industry (Bagga et al., 2020). Yet the accelerating shift in the regional and global landscape is making it challenging for the stakeholders to balance opportunities with risks. The industry is showing ramification of rapid disruption and intensified competition. Service providers are facing new playing fields. Recognizing this change alone isn’t enough. Government and entrepreneurs need to become adept at dealing with disruption and adapt the operating models, in a holistic way, to mitigate the outcomes of the shifting paradigm. It is imperative to introspect and identify the capabilities and resources that stakeholders need to realise. This is critical to endure the sophistication and competence of the medical tourism industry in India.

The outbreak of Corona virus pandemic in 2019 has further complicated the market dynamics for the medical tourism industry. Uncertainty over travel restrictions, changing quarantine measures across the world and the overall unprecedentedness of the situation, have made the entire ecosystem of medical tourism industry more precarious. With cross-border travel restrictions and the need to redirect hospital resources to treat COVID-19 patients, healthcare providers have to manage a dual burden of economic and health crises (Stackpole et al., 2021). The challenges posed by this pandemic have further demonstrated how crucial it has become for medical tourism industry in India to review their competitive positioning, access deeper competencies and build resilience.

A review of extant literature indicates very little empirical research has been done to done to examine factors of competitiveness of a medical tourism destination (Abubakar & Ilkan, 2016; Heung et al., 2010; Thayarnsin & Douglas, 2016; Yeoh et al., 2013). Theoretical understanding around the phenomena requires further academic attention (Chuang et al., 2014), specifically with regards to the perspective of medical tourism providers (Taheri et al., 2021). Virani et al. (2020) have also directed our attention to the neglect of policy-relevant research on medical tourism. This study aims to address this gap. By considering the perspective of medical practitioners and senior representatives of hospital management, this study identifies and analyses the key factors driving success in medical tourism industry and the issues that Indian healthcare providers and policymakers should address in crafting a winning strategy. Taking Delhi NCR as the context, this outlook propounds insightful research into the existing state of medical tourism industry in India, explores the dimensions and factors that can help India shape an effective ecosystem for this sector and suggests considerations for an optimum future of medical tourism industry in India.

Literature Review

The literature review encompasses a succinct discussion on the medical tourism industry, its global trends and the current state of Asian and Indian medical tourism industry, along with the key dimensions of medical tourism as highlighted in the literature.

Medical Tourism

Globalisation is restructuring the industries worldwide. Medical tourism is one such manifestation of globalisation in the healthcare industry (Connell, 2013; Ganguli & Ebrahim, 2017). Broadly it refers to travelling internationally for healthcare. Since its rapid development in 1990s, medical tourism has received a major reflection from both academia and industry. Though the growing interest to study this industry is well evident, there is still no international consent on the definition or measure of this sector. The existing literature addresses the terms health tourism and medical tourism in a loose and disorganised manner. Terms frequently used, and often synonymously, in this regard are ‘medical tourism’, ‘health tourism’, ‘medical travel’, ‘health travel’ and ‘cross-border healthcare’. While some researchers have used “medical travel” and “health travel” synonymously (Gola, 2016) others refer to health tourism as a wider field with medical tourism as its subset (Carrera & Bridges, 2006; Smith & Puczko, 2009). In agreement with Smith and Puczko (2009), this study represents medical tourism distinctly from other subsets of health tourism. The word ‘medical’ here refers to illness, disorder or injuries. As put forth by Jagyasi (2008), medical tourism is “the set of activities in which a person travels often long distance or across the border, to avail medical services with direct or indirect engagement in leisure, business or other purposes”. Contrarily, health tourism is a wide-ranging phenomenon where travel can be undertaken for a variety of reasons from preventive and health-conductive treatment to rehabilitation and curative forms of travel (Dunets, et al., 2020). Other than medical tourism, health tourism encompasses other related fields like—wellness tourism (involving relaxation and exercises) and sports/adventure tourism (involving outdoor recreation) (Hall, 2011). Medical tourism itself has sub branches like ‘reproductive tourism’ and ‘dental tourism’. Another emerging term is “domestic tourism” which refers to the act of travelling within one’s own country for medical purposes (Hudson & Li, 2012; Reddy, 2010). This study focuses primarily on medical tourism and identifies this practice as travelling internationally to receive medical treatment.

Global Medical Tourism Trends

Lack of specific data, novelty of the concept, and the fragmented and unstructured nature of this industry makes it challenging to review this industry and give an estimate of its size (Chambers & McIntosh, 2008; de la Hoz-Correa et al., 2018). Prominent market research databases have reported global medical tourism market to be worth USD 104.7 billion in 2019, and have projected it to grow at a CAGR of 12.8%, to reach USD 273.7 billion by 2027 (Chhabra et al., 2021; Taheri et al., 2021).

Even though there is no fixed estimate of this industry, medical tourism is well-considered amongst the most dynamically growing industries today. Trade economists have documented a strong impact of this phenomenon on the global economy (Bookman & Bookman, 2007) especially the emerging countries of the world (Lee & Hung, 2010; Pafford, 2009). It not only adds to their foreign exchange, but also boosts investments in the medical and tourism sector streamlining their services (Ramirez de Arellano, 2007). Asia has been specifically considered as a hub for medical tourism (Connell, 2006). Countries like Singapore, India, Thailand, Brunei, Cuba, Hong Kong, Hungary, Israel, Jordan, Lithuania, Malaysia, the Philippines, and the United Arab Emirates have emerged as major providers for healthcare services to international patients (Heung, et al., 2010). Several other countries like Mexico, Turkey, Brazil, Costa Rica, Argentina and Bolivia are also working toward establishing themselves as major healthcare destinations (Singh, 2008).

The global demand and expenditure for healthcare services is on a rise due to factors such as growing and ageing populations, changing disease patterns and rapid transformations in costly digital technologies. With the rising disparity in healthcare costs, governments, corporations and individuals are looking at outsourcing healthcare facilities to emerging markets (Turner, 2007), especially those with advance and cost-effective healthcare facilities, and a proximity to developed countries. Medical tourism is also a viable and economical option for uninsured or underinsured patients. On the other hand, there is a substantial disparity in the quality of healthcare services. Patients from countries with limited government spending on healthcare and under developed private sector are forced to look at options beyond their borders. (KPMG, 2014).

Medical Tourism Industry in Asia

Last decade has seen Asia as an emerging leader of the medical tourism industry. This growth is fuelled by the availability of a variety of high quality and cost-effective medical procedures in Asia, improved connectivity and infrastructure and along with the presence of attractive locations to explore. The availability of advanced treatments in fields such as cardiology, neurology, orthopaedic, spine, ophthalmology along with aesthetics and alternative treatments like Ayurveda, Unani, Herbal and Yoga, makes Asia a sought-after destination. With private sector as the primary driver of medical tourism in this region, Asia has seen a faster growth of this industry vis-a-vis any other region globally. Many prominent healthcare providers in Asia are internationally accredited and have positioned themselves as distinguished service providers to patients from both within the region and far beyond. A market research on medical tourism industry anticipates the medical tourism market in Asia to cross USD 14 Billion by 2022 (iGATE Research, 2017). The research reports that Thailand, Singapore and India account for maximum proportion of international medical tourists in this region, followed by South Korea and Malaysia. Philippines and Taiwan are amongst other fast emerging markets in this sector. International patients contribute to a one-third or more of revenue in these private hospitals, and hence several private hospitals in this region are targeting this global world medical travellers’ market and have also gained a strong position for themselves in the industry (Mooter, 2017). An increased focus from government, foreign investment inflows and emerging startups are fueling up the competition not just between countries, but players as well. With the competition becoming stiffer, these countries and players are becoming more proactive in building their unique identifiers. Price is no longer the only factor of differentiation, countries are now looking at founding their proposition on parameters like diverse offerings, niche market, customized offering and even luxury (KPMG, 2014).

Medical Tourism Industry in India

Healthcare is amongst the largest and most complex sectors in India and is poised to touch USD 133.44 billion by 2020 (Outlook India, 2019). Healthcare in India is becoming one of biggest industries in terms of revenue generation and employment as well. Giving further impetus to this industry is the medical tourism sector which is bolstering the level of enhancements of care services in India. Table A1, as given in Supplementary Appendix file, states some basic facts related to the medical tourism industry in India. With its key differentiating factors of extremely competitive pricing, highly trained doctors, high quality care and availability of a range of treatments, India has realized the potential of medical tourism and positioned itself as one of the largest service providers in this region (Connell, 2013; KPMG, 2014; Medhekar et al., 2019). A study by KPMG India and Google, has pegged the medical travel industry in India at USD 4.8 Billion in 2017 (KPMG India & Google, 2018). The pre-Covid estimations expected the Indian medical tourism market to reach USD 13 billion by 2020 (KPMG India & Google, 2018). Despite the deliberative effects of Covid-19 on Travel and hospitality industry, the Indian medical tourism was estimated between USD 5–6 billion in 2021 (Financial Express, 2022). A right combination of cost efficiency and quality has driven the growth of this sector in India. Table A2, as given in supplementary appendix file, gives a comparative cost chart, for some common procedures, between India and other major medical tourism destination. Further the presence of a robust private sector, with international accreditations, has reinforced India’s standing. India offers a range of treatments from cardiology, neuro, paediatrics, ortho, ophthalmology, urology, gynaecology, general surgery, dental, cosmetics along with traditional healing options (Qadeer & Reddy, 2013). As per a report by Ministry of Tourism, Government of India, around 4,95,000 medical tourists travelled to India in 2017, with Bangladesh, Afghanistan, Iraq, Maldives being the top 5 source countries followed by Oman, Yemen, Uzbekistan, Kenya, Nigeria and Tanzania (Ministry of Tourism, 2018). In the following years larger share of travel is expected from Africa and GEC countries (KPMG India & Google, 2018).Realizing the opportunity, Government of India has taken a few initiatives to promote and encourage the growth of medical travel to the country. These include Government of India’s health tourism policy; setting up a ‘National Medical & Wellness Tourism Promotion Board’ for regulatory, accreditation and marketing issues; accreditation of hospitals under the National Accreditation Board for Hospitals; dedicated website to promote medical and wellness tourism; promotions at international platforms such as World Travel Mart London, ITB Berlin, ATM, etc.; coverage under Ministry of Tourism's ‘Incredible India Campaign’; introducing separate category of medical visas—‘M Visas’; a proposal for setting up tourism circuits, along with a medical circuit which will connect modern medicine centres and Ayurveda; providing fiscal support and other benefits under Market Development Assistance Scheme (MDA); and lowering import duties on medical technology, equipment and machinery (KPMG, 2014; Medhekar et al., 2019; Ministry of Tourism, 2018).

Key Dimensions of Medical Tourism Industry

This section presents the factors, as highlighted in the literature, that impact the development of medical tourism in a region. Cost and quality are considered amongst the most important dimensions of medical tourism industry (Aziz et al., 2015; Bagga et al., 2020; Cortez, 2008). Affordability and service quality of hospitality and tourism have also been considered as important attributes for a medical tourism destination (Chuang et al., 2014; Fetscherin & Stephano, 2016; Olya & Nia, 2021).

Several studies, e.g. Ghosh and Mandal (2019) and Fetscherin and Stephano (2016), have highlighted the importance of the type of treatments offered, medical facilities, practitioner competence, service quality and standards of medical care offered by the service providers (Kamassi et al., 2020). Technological upgradation and medical innovation are other important factors linked to the success in this sector (Cortez, 2008; Velasco et al., 2013). Literature also points towards the importance of trust, credibility, perception and hence the need for certification, international standards and accreditation (Debata et al., 2015; Hall, 2011; Seow et al., 2017).

Beladi et al. (2019) and Ebrahim and Ganguli (2019) have explored the role of human resource development and administrative efficiency. Infrastructure and facilities with regards to accommodation, transportation, communication are other important dimensions recognized for medical tourism (Heung & Kucukusta, 2013; Kamassi et al., 2020).

Country specific factors and attributes such as country knowledge, culture, language, accessibility, safety and security, have also been analysed (Bagga et al., 2020; Cham et al., 2021; Olya & Nia, 2021). Crouch and Ritchie (2005) in their study have highlighted the importance of socio-cultural and political environment of the destination country. Tourism-specific factors of the destination country, such as weather, attractions, culture and exoticness, have also been considered while studying the attractiveness of a medical tourism destination (Fetscherin & Stephano, 2016; Lovelock et al., 2018).

Medical tourism destination marketing, destination branding and tourism destination image have also been considered important with respect to the development of medical tourism in any region (Hoz-Correa & Muñoz-Leiva, 2019).

Studies have also observed public and private coordination and collaboration of the medical tourism stakeholders, to enhance the development of medical tourism sector (Beladi et al., 2019; Ebrahim & Ganguli, 2019). Government support and a favourable policy framework have been considered as important factors for this industry (Hall, 2011; Wang, 2012). Snyder et al. (2015) and Omay and Cengiz (2013) have specifically advocated the need for a regulatory framework and policy intervention to improve the efficiency coordination, uniformity and standardisation in this sector and promote the medical tourism industry (Momeni et al., 2018).

Methodology

Considering the emerging nature of this industry, qualitative approach was exercised to truly analyse the value proposition of India as a medical tourism destination. A qualitative framework encourages both theoretical and applied knowledge and aids in the development of novel and alternate theories (Bygrave, 1989; Creswell, 2013). Case study method was adopted to classify and analyse the dimensions that can position India as a prominent healthcare service provider for overseas patients. Merriam (2002) describes case study as a comprehensive description and examination of a phenomenon or a social unit of study. The case being studied becomes the boundary of the research, and by focussing on a single context this approach seeks to offer an extensive enquiry and meaning of the phenomenon under study (Creswell, 2007; Miles & Huberman, 1994; Yin, 2011). For the present research, context was bounded geographically and the problem at hand was thoroughly explored in the Delhi-NCR region. As also suggested by Stake (1995), a holistic analysis of medical tourism industry in Delhi NCR allowed for an instrumental way to investigate the phenomenon at a broader level in India.

The Case Study Context: Delhi NCR

This study was conducted in Delhi NCR, i.e. National Capital Region of India. It includes Delhi, officially the NCT, National Capital Territory in India and several other regions neighbouring it; Gurugram, NOIDA and Faridabad being the prominent ones. Delhi NCR has witnessed an unprecedented growth in both, the healthcare infrastructure and as well as services in this last decade. The presence of corporate majors like Fortis, Max, Apollo; high-end hospitals like Medanta, Artemis; day care surgery centres and specialised centres, such as for IVF, eye care, birthing centres; has enabled Delhi NCR to emerge as a healthcare hub (Kachhap, 2012). Increased activity from the new corporate players have also spurred the existing older players like BLK, Gangaram and Moolchand to revive and widen their portfolio. These healthcare brands are consistently working towards building a strong medical tourism sector. With its robust medical infrastructure, advanced medical specialities, competitive pricing and highly trained doctors, Delhi NCR is amongst the most prominent healthcare destinations in India for international patients. These hospitals provide valuable services to medical tourists, ranging from special wards and lounges for international patients and their companions, translator services, international cuisines, accommodation services and the like. Moreover, its connectivity, location and rich cultural heritage and presence of international standards of hospitality make Delhi NCR a prime tourist destination. These factors make Delhi NCR an important context for exploring the medical tourism industry in India as a whole.

Data Collection

The qualitative approach and exploratory nature of this study maintains that the researcher becomes an agency for data collection. This enables the researcher to get close to the social phenomenon being studied and enable a deeper understanding of the social reality (Bryman, 1988; Marshall & Rossman, 1995). This also gives researcher the flexibility to delve into the issues that emerge during the study. The qualitative data for this study was collected by the researchers through semi structured in-depth interviews with senior practitioners, and senior members of hospital management. Conducting interviews allowed the researchers to apprehend wide-ranging perspectives and experiences of respondents with regards to medical tourism.

Potential participants for interviews were identified through purposive sampling, to ensure appropriateness, purpose and rich information. Participants were selected from multi-speciality hospitals, offering healthcare services to medical tourists, and through ongoing referrals from interview participants. Table A3, as given in supplementary appendix file, gives a brief profile of the respondents of this study. As a wide-ranging guideline for qualitative design, the study did not look for an increasing number of cases but aimed to collect an extensive detail from each case under study (Creswell, 2007). For this research the number of participant cases to be studied was not predetermined. Instead, taking reference from Maykut and Morehouse (1994), as the study progressed and data was analysed, additional cases required were determined by the extent to which each additional case would contribute to the understanding of the research problem. Data collection was concluded when it was realised that the emerging issues and themes were getting “saturated” and no new data was being found (Creswell, 2007; Glaser & Strauss, 1967; Strauss & Corbin, 1990, 1998). For this study data saturation occurred within 20 samples. Having a smaller sample size allowed the research to spend an extensive time with each case and encouraged that the understanding, of Delhi-NCR’s competitiveness as a medical tourism destination, which emerged was representative of the practitioners’ perspective (Shaw, 1999).

The interviews were conducted in the respondents’ hospitals. The interviews lasted for about 45 min. These were conducted face to face, were audio recorded, after checking with the participants, and later transcribed verbatim. Vital areas of concern were recognised after a thorough literature review on medical tourism and an appraisal of the dimensions of competitiveness of a medical tourism destination, identified by (Malhotra & Dave, 2022). These served as the guide for conducting interviews.

Data Analysis

Data was analysed by means of constant comparison method as outlined by Glaser and Strauss (1967), Strauss and Corbin (1990, 1998) and Creswell (2007). Accordingly, data collection and data analysis were done simultaneously. This allowed the researcher to make necessary adjustment to the research process, such as, sample selection, and testing the emerging themes or concepts with subsequent data (Merriam, 2002). This study has adopted the ‘abduction’ logic for data analysis. An abductive analysis approach emphasizes that instead of keeping all predefined theoretical concepts aside, a researcher should enter the field with a broad theoretical understanding and during the research process develop and build upon their theoretical repertoires (Timmermans & Tavory, 2012). As also proposed by Lichy et al. (2020), since the data set for this study was modest in size, coding was conducted manually.

The theoretical background referred to in this paper is a study, by the same authors, on the dimensions and drivers of medical tourism industry. (Malhotra & Dave, 2022) previously developed this paper based on a systematic review of empirical studies on the medical tourism industry globally. The purpose of the study was to identify and analyse the factors and dimensions that influence the competitiveness of a country as a medical tourism destination. Figure 1 outlines the dimensions identified by their study. These are structured around the domains of medical tourism opportunity and a country’s positioning, infrastructure and health human resource competence, care delivery, governance and regulatory framework.

Fig. 1
figure 1

Source: Malhotra & Dave (2022)

Factors influencing a country’s medical tourism industry.

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This study uses the extant structure to systemize its findings from research work in Delhi NCR that pursues an understanding on how the value proposition of medical tourism industry can be redefined here. This helps us explore the wider relevance of the proposed dimensions in the study by (Malhotra & Dave, 2022) and its implications in a specific context. By analysing the experiences of the practitioners from Delhi NCR, the study has able been able to identify an additional dimension that impact a medical tourism destinations’ competitiveness. This dimension is the role of medical facilitators and it has been included in the existing domain of Refined Delivery. Taken together, this has helped to emerge a more comprehensive range of dimensions that are relevant for the development of an advanced medical tourism destination.

Findings

This section organises the fieldwork findings around the dimensions outlined in the (Malhotra & Dave, 2022) study to identify any contrast and facilitate discussion on Delhi-NCR’s proposition as a medical tourism destination. These dimensions are: assessing a country’s competence as a medical tourism destination, successful positioning and government as a facilitator. While each of these dimensions have been considered independently, for analytical purpose, the apparent correlation between these three domains should be acknowledged. Along with this the discussion also includes respondents’ views on the opportunity assessment of medical tourism for India, its benefits and social implications.

Assessing Medical Tourism as an Opportunity

The ambiguity in the size or figures of the medical tourism market, as highlighted in the literature review, was also reported in the fieldwork of this study. Participants emphasised the concern regarding lack of data on the volume of value of this industry or the market shares. Almost all respondents saw medical tourism as an opportunity for India. They reflected that the market is increasing on a year-to-year basis and that there is a huge potential for the coming 5 to 10 years as well. The major reasons reported for India’s exponential growth in this segment is its clinical expertise, major cost competitiveness over other countries, conducive and friendly environment.

“Reason for the growth is that India has the advantage of being clinically excellent. Technology if not the best is at par with most other countries, our clinicians are trained abroad and they are returning back to practice in India. So clinical excellence has built up” (Respondent 9)

“Indian hospitals are clinically sound, environment is conducive, we have a price point advantage over many other countries, then we speak a language that is understood, or getting people who speak their language is easier and cost effective” (Respondent 11)

Some of the respondents also highlighted the evolution in the medical tourism industry, with destination countries getting matured and looking to invest in their own healthcare infrastructure, new medical tourist hubs coming up and a growing impetus of value driven services.

“Very soon you’ll see, facilities there will be developed, clinicians from here will go and train their people. They will still carry back procedures, which cannot be done there, because of the environment, or which require critical post-op care.” (Respondent 14)

Assessing a Country’s Competence as a Medical Tourist Destination

A well-crafted strategy can lay the foundation for a competitive destination for medical tourism and creating an environment of holistic care for medical tourists. The study shows a consensus on the competence of India and specifically Delhi NCR as a healthcare provider.

Healthcare Infrastructure

In the last decade, Delhi NCR has seen the emergence of a robust private healthcare system. Most respondents agreed that Delhi-NCR’s healthcare infrastructure, if not superior, is at par with most other destinations. And that it is one of prominent drivers of medical tourism industry here.

“In purely technical terms of medical infrastructure, I think we are at par with both Singapore and Thailand, or any other country for that matters, where they have an edge over us?? I think it’s in terms of their overall infrastructure…their ethos of cleanliness for example. It takes us an effort to do that, whereas in a place like Singapore it’s given, so that’s the challenge for us Indians” (Respondent 9)

Refined Delivery

Respondents indicate a lack of streamlined and standardised care delivery. This includes not just healthcare services, but service touch points of travel, tourism, airport and hospitality. While Delhi NCR has an appeal over factors such as accommodation, cultural adaptability, language interpreters and general conduciveness, it still has a long way to go.

“Facilities and infrastructure in hospitals are no less than anywhere else, but I think the degree of professionalism can improve a lot. Our systems and processes are not as smooth as how they should be... like the whole process starts when a patient needs medical care in a certain country, so he gets in touch with a local hospital or agent in the source country who in turn gets in tough with the hospital here, that interface could be smoother.” (Respondent 11)

“It’s not about their lack of trust on India’s healthcare system, its generally the perception of India as a country and safety of their travel. Say for e.g., patient addressal mechanism could be stronger.” (Respondent 6)

The ‘role of medical facilitators’ was not highlighted in (Malhotra & Dave, 2022) original framework. The research work in this study in the Delhi-NCR region, however, raised a number of critical systems impacts and policy implications regarding the role of medical facilitators or middlemen in the Indian medical tourism market. Participants demonstrated a consistent view regarding the prominent role of the facilitators in the medical value chain, in channelizing the international patients towards a particular country and subsequently a healthcare service provider. There was also a prevalent concern regarding the lack of transparency and regulation in the way these middlemen operate, quality of service delivered, corruption or any unethical practices, and most of all a lack of credibility. Participants expressed an apprehension on the way these facilitators impact the quality of care delivery or the overall experience of overseas patients.

“There are these middlemen, also known as facilitators, they form a very important but also the weakest link in this chain. There is no accountability, no regulation… all this can severely impact the service delivery and in turn our name, our credibility goes down” (Respondent 8)

Quality Driven by Standardized Protocols

Most respondents have recognised the importance of accreditation. Issue of safety and quality is a primary concern for the medical tourists. Delhi-NCR hospitals are accredited with both Indian standard of—National Accreditation Board for Hospitals and Healthcare Providers (NABH) and more importantly Joint Commission International (JCI).

“NABH is a recent Indian government initiative to get some sort of quality standardisation in the healthcare industry, it’s not as stringent as JCI, but at least some initiation has been done.” (Respondent 4)

“We had our first international accreditation done in 2006 and now second one around 2011–12. The Indian NABH is comparable, but it’s fairly new and not recognised well in international market. Say JCI is well recognised internationally, so we have to get that done if we want to get recognition in the international healthcare industry. Though sometime one is not able to justify the cost incurred on these international accreditations, but still they are very important.” (Respondent 15)

Enhanced Healthcare Human Resource Development

Though Delhi-NCR’s hospitals are clinically competent, lack of skill at the paramedic level was felt by several; respondents. Most respondents reflected the need for superior training programmes for paramedics, and not just in specialities but also in general category and front staff. Only then will service quality standards be met. Respondents expressed the problem of lack of retention of trained paramedics and healthcare workforce.

“Areas of improvement for us would be paramedics. We don’t have training institutes; we need to have a much more vibrant infrastructure for skilling people. Skill development is not there. One excuse given here is the numbers we deal with makes it impossible to work on trainings…” (Respondent 8)

“Doctors travel to enhance their skills, where is the exposure for paramedics? On the job training is never enough to improve their service standards.” (Respondent 2)

Coordination and Collaboration for a Superior Care Delivery

Most respondents highlighted a lack of coordination or participation at an industry level. Though several forums like FICCI, CII and the like have been recognised to have some level of representation, however these collaborations and partnerships are still at an early stage. An important reason highlighted was the clash of opinions between players. The industry is still at a fragmented state, where each hospital is strategizing to increase its share in the pie.

Successful Positioning

Most respondents spoke about the individual efforts and strategies, at the group hospital level. Each corporate is trying to position in the international market, in its own capacity. There are some efforts by the government as well in this regard.

“Yes, these corporate groups and other private players are strategizing for capturing medical tourism market, it is a big agenda for them.” (Respondent 5)

By far, Delhi NCR has been able to position itself as a clinically competent and a cost-effective player. It also scores over other players in terms of its cultural adaptability and soft service skills. Indian doctors are considered more approachable.

“On the price that we are charging, the service that we are giving is very good. We have a patient from Canada, he tells us that our service quality, the kind of attention we give is far better than what they get in west. Because, here we give personal attention, people talk to you, they are ready to go out of their way to help you…” (Respondent 3)

Government as a Facilitator

There was a mixed opinion regarding the role of government as a facilitator. A majority of the respondents felt that government should stay out of the medical tourism sector and the system. They strongly felt that any kind of intervention or regulation by the government would hamper the growth of this industry in India.

“Thankfully govt doesn’t interfere, else the business would go down. As in case of many other sectors... the fact that govt has stayed away from this business like in case of IT sector, has helped the business to come to a certain level... the moment govt steps in, and starts the process of licencing, permits, accreditation. the whole system will come down… let this run as a free market interaction, cause that will bring the best quality at the lowest price… leave the market to its business...” (Respondent 7)

The other opinion recognises the government’s efforts in a positive state. They feel the government has stepped in whenever it needs to, for visa facilitation, rationalisation of visa costs as the like. Initiatives from government and regulatory bodies are required to make the system cleaner and more transparent.

“Regulation is like a double edge sword, it helps you in certain things, it harms you in certain ways. So as long as the regulations are crafted carefully, taking in to the considerations the infrastructure of the institutions…” (Respondent 15)

Social Implications and Benefits of Medical Tourism

The widely shared outlook demonstrated the positive impact of medical tourism on a country’s healthcare and tourism industry. Participants expressed a consistent vision of an overall upgradation of both healthcare and basic infrastructure in the country as a result of the fast-growing competition in the medical tourism market. The participants typically did not express a concern on the social implication of medical tourism industry on the domestic healthcare industry of India, however suggested a holistic outlook to the entire proposition.

“We should not ague on how encouraging medical tourism in India can have a negative impact in our own healthcare burden... If you see we have come a long way, our healthcare system, our medical expertise, technology, has progressed immensely… competition is good for any industry.” (Respondent 12)

“If we talk about the impact of medical tourism on Indian healthcare industry, I should say it’s been a positive one… this proposition has added value, credibility and given us a global visibility. One can see a long-term benefit to the domestic industry, not just healthcare but other sectors as well, tourism, logistics, hospitality… Our overall standards of service and hospitality is increasing.” (Respondent 12)

Discussion

Research aimed at exploring the sources of competitiveness, in a particular industry, for firms competing in international or regional markets (e.g., Momaya, 2019; Moon et al., 2015; Thompson et al., 2013) have emphasised the role of abilities, proprietary knowledge, innovation capability, sustainable business and economic model, technological innovation, pace of internationalisation, quality, business excellence and human resources. Based on our research and taking these factors into consideration, India’s capability as a medical tourism destination is assessed below and gap areas identified. Table 1 provides a synthesis of the growth drivers for India’s medical tourism industry and the opportunity scope.

Table 1 Medical tourism industry in India—growth drives and opportunity scope.
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With increasing significance of quality and outcomes of the service (Mishra & Sharma, 2021), ‘value’ has become the watchword for the healthcare industry. The term to be used here is then medical ‘value’ travel. The addressable market is huge and several countries are strategizing to tap into this opportunity. India’s needs to build a value proposition around the right combinations of cost and quality efficiency.

Clinical expertise and cost are primarily the two important drivers of medical tourism market in India (Ebrahim & Ganguli, 2019). It has an edge over other countries with respect to its cost competitiveness. With several prominent super speciality brand names, Delhi NCR has become a hub for medical tourism. The emergence of a robust private sector has significantly enhanced the quality and standards of healthcare. With the presence of clinical and technical expertise, and international standards, Delhi’s credibility as a medical destination is on a rise. Delhi also scores high on the parameters like cultural adaptability and soft skills. The surge in emerging unconventional formats of healthcare delivery and technological revolutions are further fuelling the growth of this industry in India.

Delhi’s holistic appeal as a medical travel destination is hampered by a significantly poor perception on factors such as safety, travel infrastructure, tourism experience and streamlined systems. There have been few initiatives from the government, however much work needs to be done. Regulatory initiatives are specifically required in the areas of transparent accreditation to prevent false claims and substandard care deliveries. Most of all there needs to be a streamlined effort to bring the industry together and work on common grounds of promotion, streamlined systems and travel infrastructure. The medical facilitators play a prominent role in the medical tourism value chain. However, there is an urgent need to define and regularise their position. The channel needs to be streamlined to promote transparency in the process and curtail any unethical and unfair practice that can impact the service outcome and in turn the overall credibility.

Delhi NCR, being the capital and focal point of major developments in the country, has significant scope for improvements in airport and travel infrastructure. As in case of the hospitality industry, service delivery standards need to get streamlined in healthcare industry as well. This would mean investing in training and retaining of paramedics, not just with specialities, but general nurses and staff well.

Industry to focus on brand building initiatives, driven by digital marketing solutions and user specific marketing campaigns. Industry can leverage from collaborative efforts of the stakeholders and public private partnerships to extend potentials of enhancing expertise, efficiency and investment. Most of all it is critical to focus on factors like safety, pollution, drinking water quality, sanitation and corruption to promote a strong positive image of the country that can positively impact medical tourism industry.

As the market is getting matured, industry dynamics are changing. ‘Value’ and ‘Sustainability’ have become the operative words around the world. India and specifically Delhi NCR can look at streamlining the medical value chain by adding and generating value at each touch point, both for India and the source country. With countries which are ready to step up their healthcare facilities, India can explore the option of ‘reverse medical travel’, where in Indian doctors can help set up facilities in the source countries and train their health resources. The complicated and serious procedures will still have to refered back to India, due to the nature of procedure or the critical post-op are required. Such initiatives have already started taking place, but at a minuscule scale. Indian healthcare system needs to take a giant leap towards leveraging the unconventional operating models and technological revolutions, building an ecosystem that encourages and supports innovation. Tapping the international market in a big way will further power this growth.

Limitations and Avenues for Future Research

Case study research has an inherent limitation of generalisability. This research is limited to redefining the value proposition of the medical tourism industry in the Delhi-NCR region only. However, to get an overall perspective of India as a destination, such a study needs to get extended to other major medical tourism hubs as well, such as Chennai, Hyderabad, Kolkata, Mumbai. Also, this study is limited to the surgical aspect of the medical tourism market. Further research could also focus on another growing segment of wellness tourism. Domestic tourism is also an important but a relatively unexplored area. Other micro-niche areas can be super-specialities such as cardiac, ortho, dental, or reproductive services. Facilitators for an important but a very weak link in the medical travel value chain. Further research could focus to either remove or to strengthen this link.

Conclusion

India’s evolution, as amongst the world’s most preferred medical tourist destinations, is expected to sustain a steady growth. This growth is driven by five major factors: cost competitiveness, medical expertise, quality of healthcare services, robust private sector and cultural adaptability. Even as these factors propel India forward, there are some major gaps to bridge. The most pressing concerns in front of the Indian medical tourism industry are paucity of an amenable policy framework, inadequate tourism and logistic infrastructure, unstandardized service quality standards, and India’s poor perception on macroeconomic factors such as corruption, environment quality, safety. To successfully build a future of envisioned growth, India must place a premium on a collaborative effort from all the stakeholders, to address these issues; a commitment to innovation and sustained inclusive growth.

As for the healthcare systems around the world, COVID-19 pandemic has shaken the foundations of Indian healthcare industry as well. With business and health restrictions, medical tourism industry also suffered the initial setback (Ayittey, 2020). Government, tourism companies and healthcare providers are struggling to remodel their business to adjust to current realities, withstand the pandemic and accelerate recovery. As the trajectory of the COVID-19 pandemic is not clear, the future remains uncertain. This pandemic and uncertainty around it have further intensified the need for the industry players to direct their focus on realignment and revaluation of their business models and work towards enhancing resilience and agility.

The purpose of this research is to analyse the factors that are crucial for India to identify, create and finally deliver a distinctive value proposition as medical tourism destination. Following a literature review and a qualitative study with Delhi NCR as a case, this research advances the medical tourism body of knowledge. The paper discusses the research process and the methodology adopted for the study in detail. Finally, the report analyses India’s, and specifically Delhi-NCR’s, competence as a medical tourist destination and synthesises the key growth drivers and opportunities for this industry.

Key Questions Reflecting Applicability in Real Life

  1. 1.

    What are the critical success factors in medical tourism industry?

  2. 2.

    What are the dimensions and factors that can help India increase its competitiveness as a medical tourism destination?

  3. 3.

    How can service providers ensure a steady growth of the medical tourism ecosystem, to ensure sustainability and competitiveness?

  4. 4.

    What role can policy support play for the medical tourism ecosystem in India and its competitiveness?

  5. 5.

    How has the Covid-19 Pandemic affected the medical tourism ecosystem? Which segment of the industry can rebound stronger in which cities?