How To Bounce Back

The tourism industry could convert crisis into opportunity

The economic downturn and the terror attacks in Mumbai have adversely impacted tourism. But in many ways tourism is an antidote to terrorism; tourism is a catalyst for employment creation, income redistribution and poverty alleviation. One of the best ways to fight the terrorists is to support India’s beleaguered tourism industry.

The Indian tourism industry will be resilient and bounce back as it did post-September 2001. The present crisis presents an opportunity. There was an even bigger crisis in Indian tourism in 2001-02. The attacks on the World Trade Center in New York, war in Afghanistan, withdrawal of flights, attack on Parliament House in New Delhi and troop mobilisation on the India-Pakistan border meant that Indian hotels had just 20-25 per cent occupancy. International tour operators had removed India from their sale brochures and inbound Indian tour operators had switched to outbound operations.

Then tourism was positioned as a major driver of India’s economic growth and its direct and multiplier effects were harnessed for employment generation, economic development and providing impetus to infrastructure development. At a time, when the national tourism boards of Thailand, Singapore and Malaysia had stopped their advertising, promotion and marketing budgets, the ‘Incredible India’ campaign was launched to bring back consumer demand, generate momentum and enhance growth in the tourism industry. This was also a period when the tourist infrastructure around Ajanta Ellora, Mahabalipuram, Kumbalgarh, Chittorgarh, the Buddhist circuit and at Humayun’s Tomb was improved.

The Indian tourism sector had been crippled by the limited air services, seat capacity and high ticket prices. Changes were ushered in this sector. It started with the permission to ASEAN carriers to operate to seven Indian metros, permitting low-cost carriers to launch operations, liberalisation of charter policy, the opening up of the UK bilaterals, granting approvals to new airlines and permitting private airlines to operate on international routes. One of the most closed sectors of the Indian economy was suddenly opened up and it unleashed huge growth in both India’s GDP and higher tourism flows.

This was also the time when young entrepreneurs launched travel portals. These changed the way Indians booked their travel. It is now projected that online channels would continue to outpace the total travel market and online penetration would be nearly one-fourth of the travel market by 2010. New products like medical tourism, value, cruise and rural tourism were conceptualised and implemented in partnership with the private sector and the community.

The 2008 economic slowdown and terror attacks require another such response. The terror attacks were restricted to Mumbai. Other regions and states such as Kerala, Rajasthan, Karnataka, Tamil Nadu, Madhya Pradesh, Himachal and UP remain safe, calm and normal.

Long haul markets still make for 95 per cent of India’s international traffic. There is a need to focus on China and Japan, which will emerge as the biggest source of tourists in the coming years. Kerala as a tourism destination was unheard of almost a decade back. Its emergence was largely on account of travel diversion from terror-prone Jammu & Kashmir. Kerala, of course, had developed new products like backwaters and Ayurveda, its entrepreneurs had created experiential boutique resorts and infrastructure had been spruced up. There is a need for new states to emerge as tourism destinations by enhancing the quality of experience and improving infrastructure. In fact, the next year should see focused attention on infrastructure deficiencies which have threatened to derail India’s aim to become a world-class global destination.

The imbalance in demand and supply of hotel rooms and a near-total absence of the two- to four-star category of hotels have led to escalating prices thereby reducing India’s price competitiveness. India needs to create an additional 1,50,000 rooms in the next three years to penetrate large volume markets like China. Domestic tourism can help balance both the present adversity and the seasonality of inbound tourism. The strategy necessitates creating awareness among the rising Indian middle classes about new experiences (chasing the monsoons), new attractions (plantation holidays) as well as pilgrim circuits, heritage and monuments.

To drive growth, we need to push five critical C’s: civic governance (improving the quality of tourism infrastructure),capacity building of service providers (taxi drivers, guides and immigration staff), communication strategy (constant innovation of the ‘Incredible India’ campaign and penetration in new markets), convergence of tourism with other sectors of the Indian economy, and civil aviation (continued opening of the skies, improved airport infrastructure and rationalisation of taxes).

In the context of India, the vast potential of tourism as an employment creator and wealth distributor still remains untapped. The size of the tourism industry worldwide is $4.6 trillion whereas the software industry globally is a mere $500 billion. The tourism industry globally generates over 250 million jobs whereas the software industry generates only 20 million jobs. In India, in 2007, revenue from foreign tourists was $10.7 billion and 53 million people were employed in the tourism sector.As India grows and expands its base in travel and tourism, it will generate many more jobs and the sector will become a major catalyst for India’s growth with employment creation.

A Paradigm Shift


By the year 2020, projection is that there would be six billion tourists worldwide and tourism receipts would touch USD 2 trillion creating one job every 2.5 seconds. The Indian Government’s travel and tourism policy has given the sector further impetus. One can see many more hotels, tourist resorts, beach resorts, as well as promotion of new avenues of tourism like medical tourism, adventure tourism, rural tourism, holistic tourism, sports tourism and cultural tourism.

Commenting on the notable differences in the industry from what it was a decade back, Shubhada Joshi, chairperson, Indian Travel Congress, London says, “There are lot many products and destinations to sell.” She further adds, “Today, with open sky policies and the roads and railways getting better, there are more opportunities for people to travel. Affluence is growing and hence the spending capabilities of customers are also growing. Such situations are very rare in the history of any industry and therefore it is the best time to be in the industry.”

Talking about the industry numbers, Sanjay Narula, co-chairman, Indian Travel Congress, London notes, “Travel and Tourism, directly and indirectly accounts for 11 per cent of world’s GDP, 9 per cent of global employment and 12 per cent of global investments.”

Today, India is an emerging world power. If the world really wants to know what India has achieved in the last few years, the travel and tourism industry is the answer to that. “India being multi-cultural, there is a never ending scope in the industry. Domestic travel has been growing at 15-20 per cent p.a. Innovative sales pitches, marketing strategies and adoption of newer technologies are leading to increased sales within travel retail services especially for packaged holidays, flights and accommodation , all of which is giving us a newer global market perspective,” says Rajinder Rai, vice president, TAAI.

Challenges Faced

CV Prasad, President, TAAI says, “Very little has been done to grow domestic tourism. Lack of infrastructure is the gravest issue posing a challenge to Indian tourism and acts as a deterrent.” Domestic short haul problem is very popular. Lack of quality manpower is another serious challenge which the industry is currently facing. “There is not enough skilled manpower. The need for training institutes is a must,” Prasad stresses. Other areas where improvement is a must in order to give a boost to tourism is the need for improved roads between some tourist destinations. “There is no proper road transport quality. People above 60 travel a lot. Unfortunately, India is not equipped for them. There are no proper sidewalks,” adds Prasad. India is not positioned in many ways as far as tourism is concerned.”

Here comes the travel agent

There is no doubt that a travel agent has become an essential factor in the travel and tourism industry today. We all know that a travel agent helps travelers sort through vast amounts of information to help them make the best possible travel arrangements. They offer advice on destinations and make arrangements for transportation, hotel accommodations, car rentals, and tours for their clients. They are also the primary source of bookings for most of the major cruise lines. In addition, resorts and specialty travel groups use travel agents to promote travel packages to their clients.

Going to a full-service travel agency that sells standard travel agency goods and services, including airfare and travel packages is like a one-stop shop to the travel needs. Most travel agents provide additional services which include passport assistance, providing access to top-of-the-line equipment and supplies and a superior offering that includes access to better than average terrain and activities, accommodations, and entertainment. “The value added offerings by a travel agent is his knowledge and expertise, competitive rates, and specialty focus on various segments of travel, which translate into increased satisfaction for the customer,” adds Prasad. “Destination knowledge is a very critical aspect. The most important role that travel agents play is planning the trip. Very few people today have mastery over destinations. So a travel today has become a destination expert,” notes Shubhada. Leisure travelers can be broadly classified according to the type of trips they take, income or age. Heritage and Culture tourism, Adventure tourism, Special-Interest, Honeymoon & sight-seeing trips High-Income Travellers Budget-Conscious Travellers Families, Students & Seniors Pilgrimage Tourism, Medical and Wellness Tourism

Need for trained personnel

Like every other industry, there is a need of skilled personnel in this industry too. Besides the IATA certificate which is only academic, the personnel need a lot of soft skill training. Clients today need a host of services and not just an air ticket. It may be product knowledge, visa, insurance or foreign exchange or about a self driven car or only the weather.

“Our job is not complete unless and until we don’t give all the information to the clients. A client can get to buy an air ticket on the net. But it is still cumbersome for him/her to get all the related information. Hence, we need to be travel consultants and not just ticketing agents,” asserts Mamta Nichani, chairman, managing committee member, TAAI.

It has become imperative today to change the mindset in order to forge successful careers in the travel and tourism industry. Hitherto, the travel distribution role was performed by traditional travel agents and tour operators. They were supported by global distribution systems or tour operators’ videotext systems (or leisure travel networks). The coming of the Internet created the conditions for the emergence of interactive digital televisions and mobile devices selling directly on the Internet by allowing users to access the airline reservation systems, web-based travel agents and travel portals. This has gradually intensified competition. Consequently, traditional travel agents must re-engineer their business processes in order to survive and remain competitive. Research findings point out to the evolving nature of business in a globalised environment and the necessary strategic adjustments in human resources management.

Future of the industry

Expressing his views on the future of the travel and tourism industry and of the travel agents Prasad says, “The future is very bright. A 15-20 per cent growth can be seen in the next 5-6 years. Tourism revolution has yet to begin in India. Interest in India is beginning to catch up and it certainly has a long way to go.”

He further adds, “The internet can never replace personal contact. Travel agents are here to stay provided they adapt to the changing environment, adopt emerging technology and understand customers as well as cater to their needs.”

Says Ashwani Kakkar, CEO, Mercury Travels, “Globally, the travel and tourism industry is the single largest industry in the world. It is the best wealth distributor as an industry.”

The list is endless, for you can find many a reason and more to travel. All of these have a specific need and require knowledge of the local customs and people besides information on the destination which can be attained in a limited way from the internet. The Travel agents fulfil this very need and create not just a holiday or a trip but an experience to remember.

World flies to India for cheap cure

Travelling far and wide for health care that is often better and certainly cheaper than at home, appeals to patients with complaints ranging from heart ailments to knee pain. Why is India leading in the globalisation of medical services? Q&A with Harvard Business School’s Tarun Khanna

What used to be rare is now commonplace: travelling abroad to receive medical treatment, and to a developing country at that. So-called medical tourism is on the rise for everything from cardiac care to plastic surgery to hip and knee replacements. As a recent Harvard Business School case study describes, the globalization of health care also provides a fascinating angle on globalization generally and is of great interest to corporate strategists.

“Apollo Hospitals-First-World Health Care at Emerging-Market Prices” explores how Prathap C Reddy, a cardiologist, opened India’s first forprofit hospital in Chennai in 1983. Today the Apollo Hospitals Group manages more than 30 hospitals and treats patients from many different countries, according to the case. Tarun Khanna, a Harvard Business School professor specializing in global strategy, co-authored the case with professor Felix Oberholzer-Gee and Carin-Isabel Knoop, executive director of the HBS Global Research Group. The medical services industry hasn’t been global historically but is becoming so now, says Khanna. There are several reasons that globalization can manifest itself in this industry:

Patients with resources can easily go where care is provided.

High quality care, state-ofthe-art facilities, and skilled doctors are available in many parts of the world, including in developing countries.

Auxiliary health-care providers such as nurses go where care is needed. Filipino nurses provide an example.

“From a strategic point of view you can move the output or the input,” explains Khanna. “Applying this idea to human health care sounds a bit crude, but the output is the patient, the input is the doctor. We used to move the input around, and make doctors go to new locations outside their country of origin. But in many instances it might be more efficient to move the patients to where the doctors are as long as we are not compromising the health care of the patients.”

Khanna recently sat down with HBS Working Knowledge to discuss the globalization of health care in the context of India and Apollo Hospitals.

Q: What led you to research and write this case?

A: I came across the company during some of my travels in South India. It was so unusual to find “first-world health care at emerging-market prices” as the case says. Often better care—by which I mean technologically first-rate care with far greater “customer service” and accessibility—is available in parts of India than in my neighborhood in Boston.

Felix Oberholzer-Gee, Carin-Isabel Knoop, and I decided to write the case just because health care is such a primal thing—it arouses a lot of emotions and insecurities. After all, it’s one’s life and health that one is dealing with. And the prospect of entrusting health care to a developing country had a pedagogical “shock value,” too.

The fact that the cost of living is so much lower in India means that the same service is possible at a fraction of the price elsewhere.

Q: The term “medical tourism” is fairly new, but how new is the phenomenon of going overseas for medical treatment?

A: When I was a college student in the United States I discovered that dental care was very expensive. Even back then, many of my international classmates essentially engaged in medical tourism—they would simply bundle up the care they needed, make a trip to their country of origin, and take care of it. India was certainly one of those countries I was aware of due to my own personal background.

We didn’t have a term for medical tourism, but in a sense it was all around us. It took a set of entrepreneurs to begin to make it happen. By the late 1990s, when I was teaching courses in global strategy, some of my Thai, Malaysian, and Singaporean students were perfectly aware of the term, because these countries of Southeast Asia already had very good tertiary-care hospitals.

Medical tourism usually refers to the idea of middleclass or wealthy individuals going abroad in search of effective, low-cost treatment. But there is another dimension of medical tourism that is not called medical tourism. Narayana Hrudayalaya, a heart hospital in India, treats indigent people from neighbouring countries — Pakistan, Bangladesh, Burma—who suffer from heart disease and can’t afford surgery. Treatment for them is free. The hospital is able to provide it because surgical methods are efficient enough that pro bono care doesn’t hurt the bottom line.

Q: Why is India gaining prominence for medical tourism?

A: India is encouragingly less “scary” now. I think a lot of entrusting medical care to different locations is about a psychological fear of the unknown. An important strategic challenge for developing-country hospitals is to reduce the psychological fear.

In India, the same depth of pool of engineering and mathematical talent for software, offshoring, and outsourcing is there for medicine, too. In the 1950s and ‘60s, the Indian government invested a lot in tertiary education. By now there is at least a small handful of medical institutes that are really first-rate, and the doctors they produce are extremely well trained.

Q: What are the recruiting challenges for staffing these hospitals with doctors?

A: In the case, Prathap C Reddy, the founder and chairman of Apollo Hospitals, says he spent a lot of time studying specialists almost like an executive search firm would, to identify their pleasure points and pain points in terms of building a successful practice in the West and potentially in India. He wanted to understand not just medical training and specialties but also family circumstances, since it is always a family decision to relocate.

In the past, Indian doctors left India so they could multiply their incomes. But now we’re seeing the reversal of that. India is booming so why leave, and by the way, patients can go there.

Q: How does growth in private hospitals affect public health care in India?

A: There is an assumption in the view often expressed in the media in India and Europe, for instance, that when private hospitals in India provide care to heart patients from England, the hospitals are somehow taking care away from poor people in India. The assumption seems to be that if medical tourism was banned, the doctors in question who were catering to wealthy patients would suddenly, as a practical matter, move to a village. It takes a different set of individuals, a different set of infrastructure circumstances to create that scenario.

My guess is that the bulk of India’s problem is primary health, and has nothing to do with tertiary care. And the primary health problem is not going to be addressed by a private hospital for the most part anyway.

India is becoming a medical tourism hotspot

In a globalised world it’s inevitable that people will travel abroad for medical treatment. India is well-placed to capitalise on this trend. It has world-class medical facilities and expertise in many areas, and treatment costs can start at about a tenth of comparable treatment in America or Britain. Even if one throws in airfare, it amounts to a good bargain. According to a McKinsey-CII study, medical tourism could generate as much as Rs 100 billion of revenue for India by 2012.

The notion that catering to foreigners and rich Indians at expensive medical facilities is going to take away from health care for the poor is entirely mistaken. These are private facilities whose clients pay for their services, which doesn’t prevent the government from setting up a first-rate public health system that takes care of everybody.

It’s wrong to look at medical care as a zero-sum game. If India makes a success of medical tourism that will build bigger capacities and draw more investment for the health sector. Indian doctors who routinely travel abroad to look for work will be tempted to stay back in India. Once the market signal goes out that there are more opportunities for doctors, nurses and trained medical personnel, more young people will opt for a career in these areas.

A booming health-care sector would also spawn research and development in medical technologies, therapies and drugs in India. The advantage of having a large medical R&D establishment is not only that it would boost India’s competitive pharmaceutical industry, but also that it would spur research into diseases — such as tuberculosis and malaria — that afflicted Indians more. If India’s economy grows by an additional Rs 100 billion that generates a bigger tax base, giving the government enough leeway to raise more revenue and invest it in public health. The government shouldn’t look this gift horse in the mouth.

Move from medical tourism to medicine

It is absurd that a country that cannot provide basic health to most of its citizens should try to be a hub for medical tourism. Multi-speciality hospitals will cut into public health, unless the government lays deliberate emphasis on the latter. Doctors will be weaned away from specialising in ailments that concern the masses at large, such as HIV/AIDS, tuberculosis, malaria and gynaecological disorders, to concerns that affect a section of people, such as obesity, plastic surgery and so on.

India’s growth story will mean very little, if it does not translate into improvement in life expectancy and control of killer diseases. For every 1,000 persons there is one hospital bed. Similarly, there is one doctor for nearly 1,700. This is all the more distressing, given the India’s health and morbidity indicators. TB claims 4,00,000 lives every year. Infant mortality and maternal mortality rates, at 54 per 1,000 live births and 301 for 1,00,000 live births, respectively, are higher than even developing country levels, while life expectancy remains a laggard at 63. With such a gross mismatch between demand and supply of health services, mass health care must be awarded top priority.

Private hospitals should provide a certain minimum number of free beds. As a case before the Delhi high court on this issue argued, private hospitals are given land at below market rates, if not free of charge, and are therefore bound by social obligations. It is in large measure due to the shortage of government hospitals that health spending has become a major cause of indebtedness. Medical tourism will accentuate the shortage. Per capita state spending on health happens to be lowest in less developed states, where, in fact, the demand for health services is acute. Annual health spending of the Centre and states, at 1.39 per cent of gross domestic product, is abysmal. The Centre and states should raise health expenditure at least by three times to about Rs 1,70,000 crore per annum before they focus on medical tourism.

Medical tourism or ‘Medical value tourism’?

Top-class Indian doctors, a good mix of nursing, customer care services and treatment cost estimated to be one-sixth in developing countries as compared to developed countries, the Indian corporate hospitals are witnessing an emerging trend!

If a by-pass surgery costs $40,000 – 50,000 in the U.S., few Indian hospitals such as the Krishna Heart and Super Specialty Institute in Ahmedabad have the wherewithal to do it in around 5,000 dollars. Similarly if a joint replacement surgery costs $30,000 in U.S., the same would be done by corporate hospitals in Ahmedabad at a roughly 6,500 dollars.

India, especially Ahmedabad is the most touted healthcare destination for countries like South-East Asia, Middle East, U.K., U.S., Africa and Tanzania. And the most sought-after specialties are cardiology, joint replacement, gastroenterology, plastic, cosmetic and laparoscopic surgeries.

“There are around 3.5 lakh people waiting for treatment under the National Health scheme of U.K. The lower level workers abroad are often not covered by insurance. Countries like Tanzania do not have good medical expertise and nursing care. All of this has led to Ahmedabad contributing

greatly to the medical tourism pie in the country,” says Dr.Animish Choksi, Joint MD, at Krishna Heart Institute, Ahmedabad. Expanding into Cardiology, Orthopedic Surgery, Laparoscopic and Gastroenterology, Plastic Surgery, Cancer Surgery, Neuro Surgery, Urology Treatment the institute comprises of 15% – 20% of NRI occupancy every month.

Low costs and prompt email communication convinced Gary Konkol to travel from Wisconsin to Ahmedabad for hip replacement therapy at Krishna. “A hip replacement surgery requires a lot of assurance for me to come to India and the treatment would have costed me six times more in U.S.,” says Konkol. More than costs, Konkol feels the efficient nursing standards of Indian hospitals are better than most of the U.S. hospitals. Hansaben Patani, who underwent a knee replacement surgery at Krishna from Tanzania, feels it was lack of good medical expertise that pushed her to come to India.

Which explains, what more can be done for importance of accreditation in medical tourism? “Right from airport pick-up, to providing wheelchair to relieving the patient from anxiety regarding cleanliness, nursing care and transparency in business transactions, it is all about adding value to customer satisfaction. So it is more about ‘medical value tourism’ than medical tourism only,” Dr. Choksi concludes.

Travel Planner – 10 major travel mistakes you think you’re too smart to make

 Even the most meticulously-planned trip can go off the rails when you fall into silly travel traps. Plan and execute the trip in such a way that you do not have to deal with headaches and last-minute changes. Getting the most thrill out of a new destination depends on how foolproof your travel plans are. So before you start packing for your next holiday, here’s a pocket guide to travel know-how for a smooth experience.


Travel experts suggest that you must leave a window of at least an hour-and-a-half between connecting flights to significantly lessen your chances of missing your flight or having your luggage lost. The 30-45 minute gap is often not enough, especially at large airports where the gates are far apart and commuting from one gate to another takes a couple of minutes. And, remember, never rely on airlines to do the time calculation for you.


Certain countries demand that passports be valid for three-six months past the date of your flight home. Check the expiry date way ahead of planning your holiday. Since routine passport processing takes about four to six weeks, apply for a passport in advance. If you’re a frequent flyer, flip through the passport to check if there are enough pages. Countries like South Africa require you to have one fully blank visa page in the passport. Without the requisite number of pages, you may be refused entry.


The hardest part is knowing when to stop tracking fares and make that final purchase. Sale schemes can save you a lot of money but figure out whether they are genuine. Usually, airline ticket prices go up in the last two weeks before flying, so try to make the call before this deadline. And if you are travelling abroad, book tickets even earlier – three to six months in advance. Keep in mind that many airlines come up with discounts on Tuesdays – so if you decide to buy on a Monday, you may regret your decision when your destination goes on sale the next day.


Why pay a fare at all when you can use your frequent flier miles? But for redeeming them, you need to make a booking early. Airlines designate a very limited number of seats on each flight as eligible for reward travel, and these seats go quickly. Moreover, if you lack enough points to buy a ticket or upgrade it, remember you can amass those thousands of points when shopping for your favourite brands on the airline’s retail shopping portal. Often, you can even rent cars from affiliated companies, book restaurants and do a whole lot more – all you need to do is go on their website to check.


When the description of your hotel says “near city market”, triple check before considering it. The word ‘near’ is open to vast interpretation. A more expensive hotel in the middle of where the action is, will be far more convenient and budget-friendly than staying in the interiors and spending time and money on transport. Taxi fares in certain cities are outrageous. Moreover, if you wish to get back to the hotel and relax for a bit before having dinner, you can’t do it if your hotel is 45 minutes away from the city.


Always do your research about currency exchange centres in your city that give the best deal. When on an international trip, the most common myth is that only amateurs change currency at the airport, because the exchange rate for foreign currency will be better in the destination town. Yes, it may be, but what if you don’t find currency exchange centres at a nearby spot? If it’s an unknown city, your problem gets worse. Therefore, it’s always wise to carry a minimum amount for cab fares and other small expenses before you leave.


You loved that funky skirt at the beach stall but you’re not buying it, thinking you’ll surely get a better deal and a better version elsewhere. Unfortunately, you may not. And not having it will haunt you for the rest of your life. You may also think you can go back to that same shop if you don’t get it elsewhere. It rarely happens as you already have designated days for your travel. You’d rather visit the unexplored places. So when you like something, use your bargaining skills well and just buy it.


You may be forced to gatecheck your hand luggage. Place your valuables and essentials like jewellery, iPad, camera, house and car keys, medication — and anything else you can’t live without — in a pouch or a ziplock inside your carry-on. If you must surrender your carry-on to a flight attendant at the last minute, you can just remove the pouch and keep it with you. This way you won’t be worried about your items. Plus, you could use them whenever you need them.


Some credit cards charge a fortune as foreign-transaction fee; if you’re withdrawing a foreign currency the exchange rate will be miserably high – while others charge minimal fees or nothing. So do your research well and choose the card that doesn’t empty your pocket. A lot of credit cards offer great additional travel perks (such as extra points for dining or free checked baggage) and are free for the first year, so you can make use of them.


Sometimes, you may not stay at a great hotel but you need a good concierge to assist you with booking tours, making theatre and restaurant reservations, provide an English-speaking guide, instruct the cab drivers in the local language etc. What you can do is walk up to the concierge desk of the nearest five-star hotel. They will be happy to help even if you’re not staying with them. Just be sure to tip them.

Healing Touch

Medical Tourism Could Address India’s Health Crisis

A foreign resident needing surgical treatment is put into an international flight to India. As soon as he arrives, he is driven straight to a super-speciality hospital where he is immediately attended to by world-class doctors aware of the patient’s medical history. This trend, known as medical tourism, is already in evidence, albeit on a minuscule scale. For this to become a commonplace in a matter of a few years, medical entrepreneurs, associations of medical professionals, insurance companies, third party administrators (TPAs) and the government need to make a cogent intervention.

Like the information technology (IT) industry, India has a comparative advantage in services like healthcare. The cost differentials in healthcare between developed nations and India are reckoned to be even higher than in the IT industry. But cost is only one of the drivers. Sophisticated medical facilities in India can draw people from the neighbouring countries. In the past, trade in services implied healthcare personnel migrating to developed countries. Now, the situation has reversed, with consumers moving abroad temporarily. If this emerging potential is harnessed it could shower unprecedented economic gains on the medical community and at least a section of our society, in effect replicating the IT success story.

However, while aspiring to become a world-class supplier of healthcare services, India cannot wish away its ailing masses who lie unattended for want of decent healthcare. Indeed, the current healthcare situation in India is dismal. The number of hospital beds per 1,000 population, for example, is around one, which is well below the WHO prescribed norms, or even the low-income countries’ average of 1.5. The same shortage extends to the availability of medical and paramedical staff — this, despite India’s high disease burden. India, for example, loses 274 disability adjusted life years (DALYs) — an indicator of disease burden that reflects the total amount of healthy lives lost, to all causes — per 1,000 population compared to the developing countries’ average of 256.

No wonder India trails in healthcare outcomes. For example, life expectancy at birth in India is 63 years, compared to the developing countries’ average of 65. Likewise, infant mortality rate in India is 70 compared to the developing countries’ average of 56. A similar picture emerges in other standard indicators of health outcome. The reasons are not difficult to understand. Indian government (at all levels) spends less than 1% of GDP in as important a social sector as healthcare. Besides being highly inadequate compared to other developing countries, this limited public spending is not for the lowincome people only, as one would expect. The richer segments too benefit from it.

Furthermore, most of private spending, as much as 4.3% of GDP takes the form of out-of-pocket spending and not prepaid risk pooling arrangements, and this is highly iniquitous. Notwithstanding the insurance regulator’s announcement to grant concessions to any standalone health insurer interested in entering Indian market, the development of private health insurance has not been very inspiring.

Given all this, does it make sense to promote medical tourism? To be sure, the development of medical tourism will alter India’s healthcare landscape. While it will give a boost to the private healthcare industry by catering to wealthy foreign and domestic consumers, it could adversely hit the low-income population. Medical personnel and infrastructure would be geared to serve the elite. Medical tourists will end up driving up healthcare costs. However, the adverse effect can be mitigated through

appropriate interventions, that include greater public outlay for healthcare as well as restructuring public healthcare infrastructure, especially in rural areas. The increase in public financing of healthcare is not forthcoming, given the fiscal pressure.

It is here that promotion of medical tourism can prove to be a blessing. A part of the higher private healthcare revenue can be tapped to increase public health spending. Besides, promotion of medical tourism would have positive spillover effects. Some of these are: Benchmarking and streamlining healthcare delivery (this includes the development of treatment protocols, standardisation of costing of various procedures, accreditation of hospitals and so forth); checking brain drain from India; increasing employment opportunities; and concomitant expansion of the aviation sector.

The promotion of medical tourism requires a multi-track approach. In the international arena, it requires providing an impetus to trade liberalisation in this sector within the multilateral (or General Agreement on Trade in Services) framework, seeking harmonisation of health standards, facilitating cross-border mobility of consumers and promoting health services trade with neighbouring countries. Progress on these fronts is bound to attract greater FDI into this sector. On the domestic front, this calls for enhancing coordination between states to develop uniform regulation of healthcare, which is essentially a state subject.

The very nature of these interventions enjoins upon the government to play a pivotal role in the promotion of medical tourism, at least in the initial stages of its development. The logic of investment and profit-making in healthcare, which is no different from any other sector, will ensure a repeat of IT in healthcare, which can be made to work for the betterment of all — foreign and domestic residents alike.

What is HIFU

High Intensity Focused Ultrasound, or HIFU, is a therapy that destroys tissue with rapid heat elevation, which essentially “cooks” the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that “focal point” the temperature raises to 90 degrees Celsius in a matter of seconds.

hifu lesions labeled

Over 6000 men, in nearly 100 HIFU centers worldwide, have already chosen HIFU with the Sonablate® 500, because it is the most advanced HIFU therapy available. Discover HIFU and to see if you qualify!


What Sets us Apart?

What sets our clinic apart is our unending drive to do for the patient and the disease what is required while understanding that all patients are not candidates for this treatment at the time of clinical presentation. Success with HIFU is no different than success with any other treatment. Success is defined by treating a population with prostate cancer who are proven to have organ confined cancer. Failure diminishes our mission for success because a PSA may be too high, cancer cells were spread unknowingly through a simple biopsy procedure, cancer cells were in the seminal vesicles and we didn’t know it, or the prostate was too big or had too much calcification to be treated appropriately. You will be able to see the difference in just one phone call to our clinic in consultation with me or a short plane ride to validate our center of operation. Because the decision you make about prostate cancer will be the most significant for the rest of your life, you deserve the best. Allow me and my staff to raise the bar on the doctor patient relationship and join you on your journey to a successful outcome from your HIFU experience.

Why should I consider a prostate mapping MRI scan if I have had a HIFU procedure in India?

There are multiple reasons for a patient who has had a HIFU (high intensity focused ultrasound) procedure to consider a 3.0 Tesla MRI-Spectroscopy scan. Most noteworthy is for patients who have not nadired their PSA value at less than 0.5 ng/ml, following the procedure. This could be the first sign and the best sign that residual tissue present may be consistent with prostate cancer. Given the fact that HIFU is recognized as a definitive treatment for prostate cancer, it is generally expected that all cells treated have been ablated or destroyed by the intense thermal energy delivered; assuming that patient selection process was appropriate. Spectroscopy associated with the most precise objective diagnostic imaging technique worldwide will define cells as alive or dead based on the metabolic profile or ratio of cellular by-products: choline, creatine and citrate. An MRI-Spectroscopy scan would be the preferred method of disease evaluation when compared to biopsy. Specifically, it would not be prudent to have a biopsy when it is well known that biopsies spread cancer cells even in a post treatment setting. Remember, you can’t cure a disease once it has escaped the prostate capsule. Once it is determined that residual cells are cancerous, a salvage procedure can be scheduled including a repeat HIFU procedure.

Similarly, a rising PSA value following HIFU would suggest a less than complete ablative procedure and the return of cancer prompting an MRI-S scan. The scan will identify a specific target or region of interest (ROI) for a subsequent treatment. I generally recommend an interval of 6 months to pass prior to performing a scan to allow for an adequate healing process to have taken place. Beyond this, there are many men who want to know with certainty that the ‘scourge of prostate cancer’ has been totally eliminated. There is a deep sense of relief and satisfaction knowing that the disease has been adequately treated, allowing a man to get on with his life. Men with questions are encouraged to speak with their HIFU surgeon or call our ‘Center of Excellence’ for updated information, availability or scheduling.

Safe cure for prostate cancer

76-Year-Old Is First To Undergo HIFU Procedure In India

To reduce pain and high risk involved in surgical treatment, prostate cancer patients can now opt for a non-surgical, radiation-free procedure.

The High Intensity Focused Ultrasound (HIFU) procedure — a non-invasive and non-ionizing procedure — was introduced for the first time in Karnataka, with a 76-year-old patient undergoing it on Wednesday.

Dr S K Raghunath, uro-oncologist, Health-Care Global Enterprises Ltd (HCG), said the procedure was successful and the patient was responding well. “Since HIFU was conducted for the first time, it took time

to plan. It began at 4.30pm and ended at 8.30pm. There was no blood loss or scar. Since the patient is 76 years old, he will have to stay in hospital for a day, and will be discharged on Thursday or Friday.’’

The treatment is typically a two- to three-hour procedure performed once, primarily on out-patient basis under spinal anaesthesia. “Patients start walking within hours, and can return to a normal life within a couple of days,” he added.

HIFU technology uses ultrasound to destroy deep-seated tissue with pinpoint accuracy. “An acoustic ablation technique, it targets sound waves to the affected area, rapidly increasing temperature by 90-95 degrees in that zone, causing tissue destruction,’’ Dr Raghunath said.

A gift of health for retd teachers

On Teachers Day, 100 retired teachers with arthritis will undergo total joint replacement surgery for free.

Sparsh Foundation, a charitable wing of Sparsh Hospital, will hold ‘Sparsh Guru Namana — Tribute to Teachers’ programme from September 5 to 12 for teachers who were screened by the medical team on June 25 and 26.

The service, which costs Rs 1.5 lakh to Rs 2 lakh per patient, will also be extended to retired teachers from across the state.

They can fix an appointment by contacting the following numbers —9743214890, 9008475000 — or the Sparsh Foundation at Narayana Health City on Hosur Road, at 080 27835921/22. This is for a screening test on August 16 and 17 between 9am and 5pm at the hospital in Bangalore.

The retired teachers need to carry an ID proof of their services as a teacher and previous medical records if .


“We were able to diagnose the cancer in the early stages. After evaluating that his fitness, we went ahead with the procedure,” Dr S K Raghunath, urooncologist, HealthCare Global Enterprises Ltd (HCG), said. Before starting treatment, the age of the patient, general condition, stage and grade of the disease and patient’s preference are considered. “It is helpful for the elderly who are unfit for surgery, with little or no chance of erectile dysfunction and incontinence,” he said. Mukesh Rana, country manager, India HIFU, said the procedure confirms whether the cancerous tissue has been treated.


In India, prostate cancer is the fifth most common cancer and fourth leading cause of mortality. In 2009, 18,000 new cases were diagnosed. There has been a 1% increase every year.


  • Patients are often asymptomatic
  • No symptoms in early stages
  • Early stage cases are diagnosed either because of digital rectal exam or because of PSA blood test used for screening cancer
  • Symptoms indicate advanced stage


  • Weak urinary stream or slow stream
  • Difficulty in initiation of urination
  • Difficulty emptying the bladder
  • Burning sensation during urination
  • Blood in urine, limb endema, weight loss and bone pain
  • Incidence increasing continuously for those over 20 yrs old
  • Rise in incidence is partially caused by improved detection capability, especially using prostate-specific antigen (PSA) blood test
  • Currently, 75-85% of prostate cancers are not organ-confined in India because of lack of awareness. Hence, HCG is planning to start awareness programmes and campaigns

Surgery-free cure for prostate cancer?

New Delhi: Curing prostate cancer — the most common non-skin cancer in men — may no longer require a surgery. And what’s better, it could take just 1-4 hours time, with patients walking out of hospital in two days flat.

Urologists in India are trying out the High Intensity Focused Ultrasound (HIFU), a new technology that does not require the removal of the entire prostate gland. Instead, it “cooks the prostate tissue” with ultrasound beams, passed by a robotic arm through the patient’s rectum, destroying and evaporating all the cancerous cells.

HIFU is a one-time procedure performed under regional anesthesia and can completely cure prostate as large as 40 grams. Conventionally, surgery has been the only approach for treating many solid tumors, benign or malignant. Dr N P Gupta, president of Urological Association of Asia, says a study in 1992 had said that 6.7 per lakh population in India suffers from prostate cancer. At present, the prostate cancer surgery of choice is a robotic radical prostatectomy, in which the prostate gland and attached vesicles are removed. It is done via five to six keyhole incisions made in the abdomen. According to urologist Dr Ramesh Ramayya from Hyderabad, a radical prostatectomy, however, can lead to loss of urinary control in patients and also result in male impotency.

Gupta said around 10% patients who undergo radical prostatectomy may suffer from incontinence.

Dr Ramayya said, “Around 60% of patients also become impotent post the prostatectomy. Those who are treated by HIFU don’t suffer from incontinence at all. Only 20% in this category may suffer from impotency.”

Dr Gupta, who is also head of urology at AIIMS, said HIFU is best suited for small sized prostrates. “The normal volume of a prostate is 20 grams. HIFU is highly effective in prostates as big as 40 grams. Even though HIFU seems to be the technique of the future, at present, it’s under clinical trial and we don’t know it’s long term efficacy,” he added.

Explaining HIFU, experts said it is non-invasive. A small probe inserted into the rectum emits ultrasound waves directly to the prostatic tissue. Ultrasound energy is focused at a specific location which kills the cancer cells. In the focal zone, the temperature is rapidly elevated to 90 degrees celsius in a matter of seconds which causes tissue destruction. During HIFU, the entire prostate is treated or ablated.

Dr Ramayya said, “The treatment is pain free. People can return to a normal lifestyle within a couple of days.” “During the procedure, the probe constantly delivers real-time images of the prostate and the surrounding area, giving the physician immediate and detailed information,” he added.

Dr Ramayya, who has till now successfully cured three prostate cancer patients with HIFU, will demonstrate the technique at the international symposium on diseases of the prostate gland at All India Institute of Medical Sciences on Saturday. According to Dr Gupta, the disease of the prostate gland is a global problem with the increase in aged population. The prostate is a small gland that is part of the male reproductive system. It lies just below the bladder and in front of the rectum. Prostate cancer is usually very slow growing and is most common among men between ages 60 and 80.

Prostate Cancer Research with Transgenic Mouse Model

Prostate cancer is the cancer developed in the male reproductive system. The cancer cells can spread from the prostate to other parts of the body, such as the bones and lymph nodes. According to the past statistics, prostate cancer will likely claim more than thirty thousand lives of men in the United States each year, and some more men will be diagnosed with the disease. To date, it is believed that the primary risk factors are obesity, age and family history, but a comprehensive understanding of the causes of prostate cancer remains elusive.

Progress towards the investigation of prostate cancer has been slow due to the lack of suitable animal models that can adequately reproduce the spectrum of benign, latent, aggressive, and metastatic forms of the human diseases, helping studying the spectrum of this uniquely human disease. Although naturally occurring prostatic disease has been reported in some animal’s species, such as canine and rodent animals, these animals still fail to provide the appropriate models to adequately study the molecular mechanisms related to the early development and progression of human prostate cancer.

Researchers have started a research program to establish transgenic mouse model for prostate cancer by using a prostate-specific transgenic expression system that has been developed in their laboratories based on the rat probasin (rPB)-encoding gene. To develop an animal model for prostate cancer, they generate several lines of transgenic mice by using the prostate-specific rat probasin promoter to drive expression of the simian virus 40 large tumor antigencoding region. According to their observation, mice express high levels of the transgene and display progressive forms of prostatic disease that histologically resemble human prostate cancer. And prostate tumors have been successfully detected in the mice prostate as early as 10 weeks of age. The immunohistochemical analysis of tumor tissue has demonstrated that dorsolateral prostate-specific secretory proteins are confined to well differentiate ductal epithelial cells adjacent to, or within tumor mass. What’s more, the prostate tumors in the mice also display elevated levels of nuclear p53 and a decreased heterogeneous pattern of androgen-receptor expression, as observed in advanced human prostate cancer.

The simian virus 40 (SV40) early-region tumor antigens with the ability to induce transformation in vivo have also been used to facilitate this study. The SV40 large tumor T antigen acts as an oncoprote in through interactions with the retinoblastoma and p53 tumor-suppressor gene products, and the small tantigen interacts with a protein phosphatase. They have been used successfully in transgenic mice to induce a transformed state in a variety of systems, including pancreas, mammary gland, and others. It is believed that the directly expressing SV40 tumor antigen in the prostate epithelium of transgenic mice may provide a better mouse model for the development and progression of prostate cancer.

According to their recent study, the rPB gene encodes an androgen- and zinc-regulated protein specific to the dorsolateral epithelium (6-8) and isolation of the rPB gene has facilitated identification of cis-acting androgen-response regions within the 5′ flanking region. The ability of the prostate-specific rPB gene promoter to target heterologous genes specifically to the prostate in transgenic mice has been demonstrated. The minimal rPB promoter is specifically regulated by androgens in vivo with the ability to target developmentally and hormonally regulated expression of a heterologous gene specifically to the prostate in transgenic mice. And it has been used to target expression of the SV40 early-region genes specifically to the prostate of transgenic mice.

Nowadays, the establishment of breeding lines of transgenic mice provides an animal model system to study the molecular basis of transformation of normal prostatic cells and the factors influencing the progression to metastatic prostate cancer. The ability to induce prostatic disease in a transgenic mouse provides an animal model system to better study prostate cancer and the treatment and prevention of prostate cancer. By the way, the US-based bio-tech service company Creative Animodel, as a professional animal model service supplier, can help develop high quality transgenic mouse models for research use.

Source : Prostate Cancer Treatment in India