Healthcare Services Outsourcing to India?

This post emerged from a question asked by a friend on LinkedIn. The question was:

Are (sic) Healthcare services outsourcing from India the next big opportunity? Health-insurance companies based out of the US are giving the option to customers, to get their surgeries / medical procedures done from Indian hospitals. Is it now time to give healthcare outsourcing its due?

The question fascinates me on several fronts. I work with India investors interested in several sectors, including Outsourcing. I also work with investors keen on biotechnology and pharmaceutical sectors. In addition, I work in comparative health policy which, with my strategy hat on, I cannot help but frame in the context of the comparative advantage of nations.

As an investment opportunity, Healthcare Services Outsourcing (HSO), which also goes by the names ‘medical tourism‘, ‘health tourism’, ‘medical travel’ etc, is a no-brainer. If an investor from Britain or America wishes to invest in facilities in India that cater exclusively to economically well-heeled but health-wise, down-at-heel patients from developed countries, the returns are easy to make. The case is not hard to make from the perspective of the 3Ps of healthcare – payer, provider and patient.

The economics stack up pretty easily from the payer’s perspective although I think there is a divide between private sector payers, such as insurance companies and public sector payers such as the UK’s National Health Service (NHS). Take it with a pinch of salt, if you will, but here is an interesting ‘ready reckoner‘ of relative costs and waiting times in the NHS with those in India. The comparison does not include the cost of poorly understood risks, of corrective action when things go wrong and the cost of any adverse impact on future healthcare premia.

At least to some providers, the risks are manifestly clear. In the recent days, the UK’s NHS, which is also a payer, is asking patients to pay for corrective surgery after elective surgeries abroad go awry. For an opposite perspective – how costs to NHS add up when un-entitled foreigners abuse its free-at-the-point-of-delivery health service – see this short video from Sky News.

From the patient’s perspective, the prospect of reduced waiting times is enhanced often by the possibility of an exotic holiday in a two-fer. Not just that, patients can often get treatments which are rationed or otherwise unavailable from their provider such as obesity operations not easily available on the NHS.

The business model “HSO as medical tourism” is therefore easily fundable. The question is – in Guy Kawasaki’s succinct words – here: it is fundable, but is it viable? From the perspective of comparative advantage of India as a nation, one needs to ask: is it sustainable? Let’s examine this a bit.

India has a sufficiency of factor conditions such as good, English speaking doctors and now good infrastructure to deliver advanced surgeries and treatments. That is an attractive proposition on its own for HSO providers and seekers. But as far as domestic demand conditions are concerned, Indians carry a disproportionate burden of diseases such as malaria on the one hand, and diabetes and heart disease on the other. So there is a need. But a considerable number, estimated between 15% and 25%, remain in extreme poverty, so the purchasing power is curtailed. “HSO as business model” focuses on the factor conditions but sustainable comparative advantage for India will arise from not its relatively smaller magnitude factor conditions but also its considerable demand conditions.

The experiences of doctors in India, working on the coalface are instructive – on the one hand, about the larger failures of public health policy and practice in India, and on the other, about their value as intensive learning or potential for ‘knowledge transfer’, if you will.

Much discussion was generated by a BMJ editorial, titled Poor Countries Make The Best Teachers. My response was:

“… a doctor in the United States, who had trained in India, told me an anecdote that shows the flipside of Byrne’s experience on elective as a medical student in India, a learning experience she described as second to none. In a lecture during my acquaintance’s residency, she noticed that her professor and other residents were puzzled by the x-ray film of a boy’s limbs. They could not identify what could possibly have been wrong with him. The doctor, who had seen much rickets in India, identified it correctly and to the amazement of her colleagues. Poor countries, sadly, still provide reasons to train Western doctors in diseases that may not afflict the West right now but, with mass scale migrations, could easily become a problem in the future.”

What does this mean for investment opportunities? Well, a lot, if we think differently about HSO.

* A better, scalable and sustainable investment would lie in raising the profile of the usefulness of training doctors from developed countries in India. This will enable doctors from developed countries to understand, diagnose and treat better those diseases, which were hitherto geographically confined or eliminated, but are now resurgent and truly ‘globalised’, thanks to travel and mass migration.

* In return, the doctors from developed countries could teach the Indian doctors about innovative methods such as advanced surgical techniques, give equipment and test kits, as well as help with public health programmes particularly expanding capacity and service delivery.

* Indian healthcare system, in turn, could invest some of the profits to provide essential preventative services and public health programmes to its poor populace. India’s main factor conditions, the doctors, could therefore become not just financially better off but also more influential stakeholders in this healthier future for all.

How is that for a model for healthcare services outsourcing?

Yes, I know this is not a fashionable view. But it certainly is the most sustainable way to go forward where good health and access to good healthcare is not the privilege of the few ‘haves’ but the fundamental right of the many ‘have nots’.

As for why I am arguing a case to reduce the primacy of the potential of “HSO as medical tourism” model, I prefer to let Cicero explain that.

“The man who can hold forth on every matter under debate in two contradictory ways of pleading, or can argue for and against every proposition that can be laid down – such a man is the true, the complete, and the only orator.”

Over to you, and Santé!

Related reading:

Credit crunch and public health

Health and the Indian Economy – one of my guest posts on the Indian Economy blog

The world’s front-office? – an old post examining India’s outsourcing industry

New York Times says Uninsured Put a Strain on Hospitals. How about ‘Poverty and inadequate access to healthcare puts a strain on human beings’ for a title?